SOCIAL WORKER CARE COORDINATOR- LICSW or LMHC- LEAD, FULL TIME, 40 HOURS/ BOSTON/ Hybrid

• Hybrid schedule with 3 days onsite in one of our Longwood Medical Area offices and 2 days remote.
• This position is lead for a group of high risk, complex patients and not other social workers.

T he Integrated Care Management Program is part of MGB Center for Population Health for high-risk patients who are medically, psychiatrically and socially complex. The is a key member of the iCMP team working effectively with interdisciplinary health care professionals to identify high-risk psychosocial factors of patients and families that impact health status. The Social Work Care Coordinator Lead facilitates the management of care for this defined high-risk population.

The Care Coordinator Lead collaborates with the care team to create and improve the iCMP system of care. The position requires a high degree of leadership, flexibility, independence, and teamwork. The Care Coordinator Lead must have strong communication and behavior motivation skills. This includes the ability to engage easily with patients, their caregivers, primary care practice staff, community resources and the iCMP team. The Care Coordinator Lead works with the care team to ensure patients are receiving the right care and services, at the right time in the right setting, achieving an optimum quality of life for the patient. This may include engaging with patients in the home setting, outpatient area, non-acute setting or other areas.

The Care Coordinator Lead is identified as a nurse, social worker, licenced mental health counselor or community health worker with broad knowledge of clinical care, systems management, and care coordination. The Care Coordinator Lead evaluates, develops a plan of care, and facilitates the trajectory of patient care. Depending on the dominant patient care needs, the Care Coordinator Lead applies their individual skill sets to effectively manage the medical, social, or resource needs of patients.

The Care Coordinator Lead is involved in the assessment and triage of patients and families to ensure provision of appropriate, timely, and effective evaluation. An initial evaluation may be conducted by the Care Coordinator Lead independently, or in collaboration with other members of the iCMP care team. The Care Coordinator Lead works with the care team and communicates relevant information. Care plans are prepared in conjunction with the clinical team. The Care Coordinator Lead may provide direct intervention to patients and families and may work with the treating clinicians including psychiatry, psychology, or other Specialty disciplines, within and outside of the Partners Healthcare system, helping to ensure that treatment is focused and effective.

PRINCIPAL DUTIES AND RESPONSIBILITIES

1. Reviews and assists in triaging new iCMP patients with the PCP, Psychiatrist, and other members of the iCMP care team as appropriate.
2. Completes comprehensive, discipline specific, initial assessment of patients to evaluate health needs including but not limited to mental health, emotional issues or coping style, understanding of illness, adjustment and compliance, barriers to care, abuse and/or neglect, domestic violence and substance abuse. When abuse or neglect is suspected, files mandated reports as indicated by local organizational guidelines.
3. As appropriate, depending on the Leads skill sets, provides additional bio-psychological assessment based on clinical complexity Determines family relationships and support systems as they relate to the care of the patient. Identifies family decision makers and caregivers; family understanding of illness and trajectory of care. Identifies family coping style, family resources, and cultural issues.
4. Identifies key barriers to care and patient’s ability to manage their health and provides appropriate referrals to iCMP team members including but not limited to Pharmacists, Community Resource Specialists, and Behavioral Health Specialists.
5. Working with the care team, the Coordinator Lead develops a comprehensive care plan appropriately utilizing the menu of services available for patients including community services. Ensures the timely implementation of the comprehensive care plan and communicates the trajectory of care to the patient/family and members of the care team. Continually re-evaluates the care of plan to continually optimize care coordination.
6. Monitors patient progress, intervening as necessary and appropriately to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost-effective.
7. Communicates with Primary Care Physician and/or Psychiatrist and other care team members about patient care plan on an ongoing basis.
8. Acts as liaison monitoring iCMP patients in acute and non-acute facilities, assessing and identifying patients with complex medical discharge planning and continuing care issues, and refers to other members of the care team as appropriate.

QUALIFICATIONS:

1. Education: Master’s of Social Work Degree or Master's in Mental Health Counselor from an accredited program required.
2. Licensure: Current Massachusetts Licensed Independent Clinical Social Worker (LICSW) or Licensed Mental Health Counselor (LMHC) required.
3. Will also consider candidates with LCSW for Social Worker Care Coordinator.
4. Monitors patient progress, intervening as necessary and appropriately to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost-effective.
5. Bilingual (English, Spanish highly preferred).
6. Understanding of medical and psychosocial conditions. Ability to work with the families/caregivers of such patients and help patients and families/caregivers gain access the resources required to support care.
7. Demonstrated commitment to impacting the care of high-risk patients.
8. Ability to use understanding of complex medical and psychosocial conditions to formulate succinct case summaries.
9. Good organizational and time management skills.
10. Demonstrated ability to communicate effectively orally and in writing.
11. Strong interpersonal skills enabling effective team collaboration.
12. Demonstrated ability to be flexible and adapt to a complex, fast-paced medical environment.