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Job Details


Category: Social Work
CHA Somerville Campus, Somerville, MA 02143

Department: Primary Care Complex Care Mgmt
Job Type: Per Diem
Job Class: Union
Work Shift: Days
Work Days: 8:30 - 5 PM
Hours/Week: 0
Date Posted: 08/23/2021
Requisition Number: hrq-118289

Job Details


The Social Worker Care Manager (SW CM) serves as a member of a multi-disciplinary Complex Care Management Team to identify and intervene with high risk patients at assigned primary care sites as part of an innovative Accountable Care Organization. Care management teams (nurse, social worker and community health worker) support high risk/high utilization patients to utilize the healthcare system optimally and engage effectively in their individualized health plan. Team members work remotely from home and interact with patients and care team members via phone, EMR, and virtual meetings, along with occasional home and community/clinic visits. SW CMs follow identified patients who may have two or more co-morbid diagnoses including psychiatric illness, alcoholism and/or substance abuse. This position will have a set assignment with two or more primary care site teams located in Cambridge, and/or Somerville, but may also work with patients at other sites in Malden, Everett, and Revere.

Job Purpose:

Works as part of a complex care management (CCM) team to screen high risk/high utilization patients. Conducts comprehensive assessments of patients to identify drivers of poor health outcomes and develop individualized care management plan in collaboration with patient and care team. Works with payers, caregivers and clinical staff to provide goal-oriented, coordinated care and health management for individual patients. Collaborates with staff at anchor site to foster a meaningful and collaborative approach to health management for identified patients. Provides leadership for a collaborative multi-disciplinary team process by establishing a meeting agenda and support for the team in care plan implementation for multiple patients with psychosocial, behavioral and medical needs. Identifies and manages risk for specific populations, eg. homeless, substance using, elders, disabled. Contributes to an innovative, collaborative team process which values collegial and supportive teamwork, and continuous learning and process improvement.

Master's degree in Social Work or an equivalent related degree.
Current MA licensure as LICSW (Licensed Independent Clinical Social Worker) or eligibility for licensure.
LCSW (Licensed Clinical Social Worker) is adequate when pursuing required supervisory hours in order to be eligible to register for LICSW exam within 2 years of hire. CCM certification or equivalent preferred.

Minimum of two years post master's degree, in clinical or human service setting with relevant populations.
Bicultural and/or bilingual candidates (Spanish, Portuguese, Haitian Creole or others) preferred. Experience providing compassionate, respectful care with low income populations with mental illness and addictions strongly preferred. Understanding of medical care, chronic disease treatment, and utilization management across the care continuum strongly preferred. Must be self-directed, and able to function collaboratively in a team environment. Strong computer skills, including Microsoft Word, Excel, and EMR (Epic) skills highly desirable.

This position is remote/hybrid with ability to travel within the CHA Service Area (Cambridge, Somerville,
Revere, Everett, Malden) required.


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