Job Description

Job Title: Social Worker Case Manager

Job Location: Cambridge, MA (Role is 100% onsite)

Job Duration: 3 Months contract with possible ext.

Note:

Hours per Day 7

Hours per Week 20

Needing a medical social work case manager with experience in a hospital or internal medicine clinic.

Masters in Social Work

Required Education

• Master's Degree
• Required occupational training, certifications or license(s)
• Required – Masters in Social Work. Current license to practice social work in Massachusetts, either LCSW or LICSW.
• Preferred - Case management certification preferred.

Worker must provide a Letter of Good Health, signed by a physician, and an immunization record that shows compliance with HUHS Immunization Policy, to HUHS HR, on first day of assignment.

Business Title: Ambulatory Social Work Case Manager

Assists HUHS patients and their families in coordinating medical, social, emotional, insurance, and vocational issues related to injury or illness. Conducts psychosocial assessments, either in-person or telephonically, in order to develop a comprehensive out-patient care plan that guides work with patient. Collaborates with physicians, nurses, support staff, community agencies, and other health care professionals to implement safe, effective, and timely patient care. Communicates with treating clinicians on areas of concerns and provides clinical updates to clinicians on a regular basis. Provides timely and appropriate documentation in patient's electronic medical record. Participates in assuring that HUHS is in the forefront of applying Case Management principles. Participates in achieving the goal of cost effective, high quality, continuous care to patients; communicates effectively with clinicians, patients, and team leader to achieve this goal. Utilizes team leader as appropriate for clinical consultation and to apprise of legal, ethical, risk issues that may affect the patient, family, or health services. Maintains quality assurance and improvement activities in compliance with HUHS standards. Assists in development of reports and resources required by other departments.

Required

Masters in social work. Current license to practice social work in Massachusetts, either LCSW or LICSW. Minimum of 2 years of social work experience in medical setting. Familiar with managed care and case management principles.

Preferred

Ability to work independently and as part of a team. Familiar with care needs of medically complex young adult, adult, and geriatric populations. Ability to provide a high level of customer service to patients, staff, and external customers in a professional, service-oriented, respectful manner in using skills in active listening and problem solving. Excellent organizational, analytical, problem solving and interpersonal skills.

DUTIES AND RESPONSIBILITIES

• Assumes responsibilities of an active caseload, including following patients throughout the continuum of care.
• Provides Ambulatory Case Management services to identified HUHS patients through a process of research, patient interview, development of care plans and monitoring of care.
• Researches clinical history of identified patients using all necessary and appropriate resources.
• Provides a clinical assessment either telephonically or as appropriate in person to assess patient’s needs and perception of their health status.
• Provides pre-operative outreach and assessment to identified student athletes.
• Assists HUHS patients and their families coordinate medical, social, emotional, insurance, and vocational issues related to injury or illness.
• Educates patients and families regarding Advance Directives and assists patients and families in completing Advance Directives.
• Promotes effective communication with hospitals and their departments. Educates them to resources available at Client Health Services.
• Participates in/attends IM Team Meetings and daily huddles.
• Participates in/attends HUHS committees/work groups when appropriate.
• Communicates with primary care clinician, patient, and home care provider to ensure medically necessary services. Regularly communicates with patients requiring post- discharge service to assess patient satisfaction and that appropriate services are in place.
• Evaluates utilization and effectiveness of Home Care provider network.
• Assess quality of care of Home Care providers as well as responsiveness. Addresses areas of concerns with manager to ensure optimal quality of care for patients.
• Educates patients/families about non-skilled services for patients when necessary. Assists in arranging for these services when patients/families allow.
• Acts as a liaison between patients and HUHS to assist in coordinating follow up services.
• Ensures the department maintains effective communication with other HUHS Departments.
• Educates HUHS staff about Care Coordination’s scope of service and how to utilize HUHS case managers as resources.
• Identifies areas of improvement; recommends and implements solutions.
• Actively participates in project development. Collaborates with manager to implement, evaluate, and support programs to maximize utilization of available resources.
• Assists in maintaining a Quick Reference Resource Guide.
• Educates patients/families/caregivers as to trajectory of certain disease processes and level of support/care needed throughout disease process.
• Educates patients/families about health insurance processes and when appropriate benefits. Directs patients/families where to learn more about health insurance benefits.
• Provides supportive counselling to patients and families to enhance coping skills and resolve concerns.
• Provides supportive counselling to patients and families considering changes in living situations or managing changes related to a medical condition.
• Collaborates when appropriate with BCBS MA Nurse Case Manager in case management of HUSHP/HUGHP patients with complex medical and psychosocial needs.
• Develops a comprehensive treatment plan. Monitors and assesses appropriateness of treatment plan and makes appropriate modifications as necessary.
• Communicates with PCP or treating clinician on areas of concern in addition to ongoing updates on clinical progress.
• Reports incidences of suspected abuse and neglect of children, elders, and individuals with disabilities to appropriate designated state agency.
• Organizes and participates in patient case conferences as needed Provides timely, appropriate, comprehensive clinical documentation in patient's electronic medical record.
• Provides cross coverage for co-workers as needed.
• Attends department staff meetings.
• Is punctual and prepared for duties at start of shift.
• Is reliable and dependable in coming to work.
• Gives appropriate notice to manager when unexpected circumstances call for staff member to be away from work.
• Utilizes time productively.
• Participates in the orientation of new staff members.
• Identifies own learning needs and requests assistance from others when needed.
• Works independently, as well as collaboratively, with all members of the health care team.
• Treats patients with dignity, respect, and compassion.
• Provides prompt care/service and behaves sensitively in all interactions.
• Deals with others in a sensitive, tactful, positive, and courteous manner.
• Accepts and acts upon feedback.
• Utilizes team leader as appropriate for clinical consultation and to apprise of legal, ethical, risk issues that may affect the patient, family, or health services.

AGE SPECIFIC and CULTURAL COMPETENCIES:

• When communicating with the geriatric patient pays attention to potential auditory deficits. Adapts qualities of voice (volume, tone and speed) as appropriate.
• When providing documentation to the geriatric patient, pays attention to visual needs. Utilizes larger size font as needed.
• While meeting with the geriatric or disabled patient provides appropriate environment for patient. Modifies office space to accommodate wheelchairs or utilizes conference rooms when meeting with patient and family members.
• Utilizes community agencies specific to the geriatric patients as needed. Provides information on such programs as Meals on Wheels, Elder Services Council on Aging, etc.
• When making arrangements for home care services identifies professional with appropriate skills to provide care.
• When speaking with young adult provides a comfortable and confidential environment.
• When appropriate, allows young adult to maintain control while providing information and suggestions.
• Assess patient’s ability to manage issue; encourages parent and/or adult participation, as necessary. Notifies appropriate adult and/or staff when met with resistance, as needed.
• Coordinates with necessary individuals such as university staff and/or parents in discussion of student issues when appropriate.
• Recognizes impact of illness on ADLs, family, and financial responsibilities.
• Assesses patient’s ability to cope with impact of illness. Provides support and education on available resources, i.e. CAMHS, BH, disease specific support groups, etc.
• Encourages and promotes adult in maintaining optimal level of functioning and independence.
• Is aware of and sensitive to differences in patients’ demographics, including race, ethnicity, socioeconomic status, gender, age, disability, literacy levels, sexual orientation and gender identity, in order to make informed decisions regarding what best fits his/her needs and lifestyle.

COMPLIANCE:

• Adheres to the expectations and professional responsibilities of the department.
• Adheres to the HUHS Code of Conduct.
• Employs the standards, practices, and procedures of the department.
• Completes and complies with HUHS training requirements including HIPAA Privacy and Security.
• Reports non-compliance incidents to the supervisor, manager, and/or Compliance Officer.
• Wears modest, neat, professional business attire. Wears identification badge.

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