Social Worker ACO

Location: Beverly, MA
Job ID: 154556-1A
Date Posted: Aug 6, 2019

Job Description

Welcome To

Lahey Health Shared Services is part of a vibrant and growing health care system, recognized as a trailblazer in medicine and a standard bearer in patient experience. It includes an award-winning academic medical center, a superb constellation of community hospitals, home care services, rehabilitation facilities and more.

We are committed to attracting, developing and retaining top talent in a market long recognized and revered as a global leader in health. With a team approach to care, we encourage learning and growth at all levels, and we offer competitive salaries and benefits. We adhere to the principles of a just and fair work environment for all colleagues, where respect is foundational and performance is rewarded.

About the Job

Lahey MassHealth ACO (LMH-ACO) is responsible for improving coordination of patient care, reducing unnecessary hospitalizations and readmissions, emergency department visits and revisits, and reducing total cost of care over time.  LMH-ACO will provide services in collaboration with contracted Managed Care Organizations as well as Community Partners for Behavioral Health and Long Term Services and Supports, as appropriate.

The Social Worker, LMH-ACO, 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 develops and maintains a therapeutic relationship with the patient, which may include linking the patient with systems that provide him or her with needed services, resources, and opportunities. Services provided under the rubric of the Social Worker’s Case Management practice may be located with Lahey Health and/or spread across numerous different organizations.

Utilizing medical management techniques the Social Worker supports LMH-ACO in avoiding hospitalization when possible, shortening unavoidable hospital stays, and reducing total cost of care by discouraging the unnecessary use of medical services.  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 LMH-ACO 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, LMH-ACO.


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.

  • Delivers care that is specific to the age/ability of the patient.

  • Evaluates effectiveness of care and adapts plan based on patient/caregiver response. Supports Lahey Health’s commitment to community based resources both within the Lahey community and beyond.

  • Participates in development of a high performing MassHealth ACO with a Patient Centered Medical Home (PCMH) emphasis collaborating with all disciplines with a specific focus on tangible outcomes related to improved quality, patient / provider satisfaction, and decreased costs.

  • 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.

  • Advocates for patient and families, responds to and facilitates resolution of patient questions and concerns.

  • 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 2-5 community health workers.

  • Provides outreach and support to individuals with a history of high utilization of healthcare services.

  • 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.

  • Works collaboratively with other professionals to maintain a team-oriented approach to case management and incorporates shared decision making in all patient interactions.

  • 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, pharmacists, community health workers, and other members of the care team throughout the continuum of care including acute hospital, skilled nursing facility, acute rehabilitation, and home care.  The Social Worker will be responsible for insuring the transitions of care are handled well and the needs of the patient/caregiver are anticipated and met.

  • Makes referrals as needed to appropriate medical/psychology/behavioral health professionals and to appropriate community programs/resources.

  • Works collaboratively with LMH-ACO’s LTSS and BH Community Partners and other community agencies to ensure a patient-centered care plan is developed and maintained for patients with LTSS and/or BH needs

Leadership Competencies

  • Demonstrates professional behavior by adhering to unit policies and procedures, practice guidelines specific to the setting and the National Association of Social Workers’ Code of Ethics.

  • Demonstrates skills as a responsive team member.

  • Demonstrates clinical leadership as evidenced by supporting research and development of care pathways.

  • Demonstrates role of social worker as teacher and coach.

  • Demonstrates ability to fulfill role in supporting LMH-ACO in regulatory compliance as appropriate.
  • Practices in accordance with applicable state and federal regulations, statutes, and laws.



  • LICSW, Masters in Social Work 

Licensure, Certification & Registration:

  • Current Active, unrestricted Massachusetts Social Work License required.


  • 5 years medical or community based social work experience is preferred.

  • Excellent clinical, interpersonal and communication skills. Must be able to work collaboratively with other healthcare professionals as well as independently. Experience working with the chronic, complex and/or behavioral health population in a physician management service organization is highly desirable.
  • Must be proactive, assertive, and possess creative problem solving skills.
  • Experience with MassHealth population, managed care, ACO, medical home or integrated case management environment highly desirable.
  • Must be proficient in computer skills, internet, information technology and electronic medical record use. Epic experience highly desirable.

Skills, Knowledge & Abilities:

  • Demonstrates expert practice skills that include flexibility, priority setting, problem-solving, conflict resolution, negotiating and networking skills, decision making, work delegation and organization, and verbal / written communication skills.

  • Demonstrates effective teaching techniques applying adult learning principles.

  • Demonstrates ability to coordinate appropriate educational materials for patients and their support systems.

  • Demonstrates sound knowledge bases and actions in the decision making process for designated patient populations.

  • Excellent interpersonal and organizational skills.

  • Knowledge base of psychosocial care, case management, social work, community resources and related regulations.

  • Ability to manage and provide leadership to an interdisciplinary group.


About Us

The Lahey Model of Care—right care, right time, right place—is exactly what patients, providers and payers need and deserve. Identifying and delivering on this convergence of interests has positioned Lahey Health for further growth. Our model ensures care is highly coordinated and locally delivered, with lower costs and exceptional quality.

Lahey Health is a robust, regional system including a teaching hospital, community hospitals, primary care providers, specialists, behavioral and home health services, skilled nursing and rehabilitation facilities, and senior care resources throughout northeastern Massachusetts and southern New Hampshire. The system has a global presence with programs in Canada, Jordan and Bermuda.

Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.