Tufts Medicine is a leading integrated health system bringing together the best of academic and community health care to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. Comprised of Tufts Medical Center, Lowell General Hospital, Melrose/Wakefield Healthcare, an expansive home care network and a large clinically integrated physician network, Tufts Medicine has more than 15,000 dedicated employees and caregivers.

We Are Hiring MSW Social Workers or Clinical Mental Health Counselors! Apply Today To Learn More About Our Updated Salaries

Job Overview 

This position supports and facilitates a patient’s transitions of care following hospital utilization through telephonic patient outreach and coordination of care among team members and outpatient providers and agencies. Act as a key point of contact for the team and a liaison between providers and clinical resources, ensure the patient follows post-discharge plans with a goal of preventing avoidable readmissions. This position supports clinical operations by creating daily patient activity reports and sending to provider offices, reviewing and authorizing referrals, and preparing level of care reports.  Helps ensure patients are receiving comprehensive and coordinated care. 

Minimum Qualifications

1. MSW - In Social Work or Clinical Mental Health

2. Two (2) years working in a clinical setting  

Duties and Responsibilities

The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list.  Other duties and responsibilities may be assigned. 

1. Works within the EPIC Compass Rose platform to triage referrals to the Population Health Department daily; including census/admission/discharge-based assignments. 

2. Ensures the EPIC Care Management & Behavioral Health work queues are up-to-date throughout your designated shifts. 

3. Completes required documentation in EPIC as well as other department-sponsored databases in a timely and accurate manner. 

4. Operates as the EPIC Compass Rose work queue 'subject matter expert'; being a resource to team members, Primary Care practice staff, and other collaterals who refer into the department. 

5. Acts as the primary contact for internal and external collaterals; such as health plans, Primary Care practices, and Community Partners. 

6. Develops trusting and professional relationships with our internal and external collaterals; engaging respectfully and with the utmost attention to service. 

7. Responds promptly to requests made to the department and leverage team members when appropriate. 

8. Becomes well-versed in other platforms in order to properly process referrals. 

9. Provides coverage to teammates as well as other administrative roles within the department as needed to maintain seamless operations. 

10. Runs regularly scheduled reports for management to review and analyze team performance, referral volume, and overall program trends. 

11. Collaborates with management to ensure workflows are adequately meeting the needs of the department and the patient