Care Manager Social Worker - Medicare

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

As a Social Worker within Beth Israel Lahey Health Performance Network, you will have the opportunity to make a profound impact on the lives of people living with multiple chronic illnesses as well as vulnerable populations with complex medical, social, and behavioral health needs. This position is responsible for supporting Beth Israel Lahey Health Performance Network ‘s (BILHPN) value-based care initiatives within risk contracts and ACO’s, working collaboratively with primary care, ambulatory and post acute settings. . The overarching goal is to improve coordination of patient care, reducing total medical expense over time. The Social Worker addresses both the individual’s psychosocial status as well as the state of the individual’s healthcare support system, facilitating interventions at the patient and family as well as system levels. The Social Worker links the patient with systems that provide him or her with needed services, resources, and opportunities.



The Social Worker supports value based care initiatives which aim to reduce total medical expense. The Social Worker ensures that the patient obtains the best and most appropriate treatment by encouraging the most effective and cost efficient use of health care and related services.



The Social Worker provides care coordination for a patient's care throughout the care continuum including hospital stay, post-acute care and chronic care community services. Consistent with the Triple Aim, The Social Worker seeks to enhance quality and patient experience of care while eliminating unnecessary costs for patients.



Working with the team, the Social Worker monitors appropriate utilization of healthcare resources and promotes quality and efficiency by developing and implementing a patient-centered care plan. The Social Worker is accountable for ensuring efficient and professional social work services for patients and families that are designed to promote and enhance their physical and psychosocial functioning with attention to the social and emotional impact of illness and disability.



The Social Worker upholds the current standards of social work case management practice and reports to the Manager of Care Management

Job Description:

Essential Duties & Responsibilities (including but not limited to): 
-Accountable for providing safe patient care by demonstrating organizational skills that maintain and coordinate safe delivery of quality care for assigned patients/families.  

-Develops a culturally competent plan of care that identifies patient problems, expected outcomes, and addresses preventative measures. 

-Aims to improve patients’ overall quality of life within the community by supporting treatment goals, empowering them to be advocates for themselves and assisting them to obtain benefits, access to health care and social services. 

-Provides care coordination for individuals with multiple social stressors and/or behavioral health concerns. Utilizes screening criteria developed for the overall purpose of coordination of quality health care services, reduction of service fragmentation, enhancement of quality of life, and the appropriate use of health care resources. 

-Supervises a team of 0-5 community health workers. 

-Assists in obtaining advanced directives. 

-Assists in facilitating access to healthcare, including by arranging access to social services such as arranging transportation to medical appointments. 

-Works independently providing case management services based on a comprehensive psychosocial assessment including addressing cognitive functioning, functional status, culturally sensitive issues, patient/caregiver support system, insurance, financial status and home & community environment. Uses this information to develop a patient-centered care plan and shares this information with patient/caregiver and healthcare team. 

-Conducts reassessments on an ongoing basis, including at prescribed intervals and whenever there is a significant change in the patient’s health, abilities, living situation, and family involvement. 

-Collaborates with the patient/caregiver and healthcare provider to formulate an individualized effective case management plan of care and implementation strategy, including by identifying the patient’s strengths and support systems. 

-Participates in quality improvement activities aimed to improve patient-population outcomes and associated processes. 

-Offers community-based care coordination for individuals in need of support and outreach in order to successfully engage medical, behavioral health and social services in the community. 

-Works closely with nurse case managers, p