Unclassified - Weymouth, MA
posted 3 months ago
Full-time - Mid Level
Remote - Weymouth, MA
About the position
The Clinical Social Worker Care Coordinator at Brigham Health Harbor Medical Associates plays a crucial role in supporting high-risk patients within the Integrated Care Management Program (iCMP). This full-time position involves collaborating with healthcare teams to develop and implement comprehensive care plans, ensuring high-quality, cost-effective care for patients with complex medical and psychiatric needs. The role requires a blend of on-site and remote work, with responsibilities that include patient assessments, care coordination, and advocacy for patients and families.
Responsibilities
- Review and assist in triaging new iCMP patients with the PCP, RN Care Coordinator, and other members of the iCMP team.
- Complete comprehensive bio-psychosocial assessments of patients to evaluate clinical needs.
- File mandated reports when abuse and/or neglect is suspected.
- Provide psycho-social assessments of families to determine family relationships and systems related to patient care.
- Develop comprehensive care plans in collaboration with the Care Team.
- Provide direct and ongoing care management to select patients and refer to existing care management programs as needed.
- Ensure timely implementation of care plans and communicate critical elements to patients, families, and care team members.
- Monitor patient progress and comprehensive care plans using internal and external data and guidelines.
- Establish a communication schedule for periodic contact with providers and patients to review status and progress.
- Evaluate, coordinate, manage, and document relevant information in patient electronic medical records.
- Identify key barriers to care and the patient's ability to manage their health and wellness.
- Communicate with other healthcare clinicians about patient care and follow-up plans.
- Provide necessary iCMP assessments upon discharge from inpatient admissions.
- Offer caregiver/family counseling or support to promote cohesiveness and ability to provide care.
- Prepare patients and families for care transitions, including end-of-life care.
- Advocate for patients and families to gain access to services and resources.
- Coordinate family/team meetings when appropriate.
- Provide consultation to practice staff regarding patients not in the high-risk program.
- Act as a resource to the care team on managing psychosocial and substance abuse issues.
- Collaborate with PCP and/or iCMP Manager and Medical Director on challenging patient situations.
- Attend and present in case reviews, seminars, and program meetings.
- Participate in regular meetings with iCMP Manager and Medical Director to review performance and goals.
Requirements
- MSW/LICSW or LCSW working toward LICSW
- Five years of experience in psychiatry, substance abuse, trauma, and/or community mental health services preferred
- Clinical experience with patients of all ages suffering from complex medical and psychiatric problems
- Strong understanding of psychiatric and family systems
- Knowledge regarding end-of-life care
- Demonstrated ability to be flexible and adapt to a complex, fast-paced medical environment
Nice-to-haves
- Experience in community resources and care management programs
- Familiarity with electronic medical records and care management databases
Benefits
- Health insurance
- Dental insurance
- 401k retirement plan
- Paid time off
- Flexible scheduling options
- Professional development opportunities
