Social Worker Care Coord - MSW

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Location: Winchester, MA
Job ID: 161011-1A
Date Posted: Oct 19, 2021
Category: Clinical Professional

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Job Description

Welcome To

Welcome to Winchester Hospital, part of Beth Israel Lahey Health. Winchester Hospital was the first hospital in Massachusetts to earn Magnet recognition, the American Nurses Association’s highest honor for nursing excellence, three times. It has since received the recognition a fourth time. As the northwest suburban Boston area’s leading provider of comprehensive health care services, the 229-bed facility provides care in general, bariatric and vascular surgery, orthopedics, pediatrics, cardiology, pulmonary medicine, oncology, gastroenterology, rehabilitation, radiation oncology, pain management, obstetrics/gynecology and a Level IIB Special Care Nursery.


About the Job

JOB SUMMARY:  Contributes to the Hospital’s mission by performing two roles:  1.) providing our patients with a safe plan of care for discharge and 2) providing social work services to patients and their family members.  This professional licensed position will have an impact on finance and growth by classifying patients’ status appropriately.  They will impact the patient experience and quality of care by working with the patient/family to establish the best plan of care and by helping patients through difficult situations.




Required:  Master’s Degree in Social Work  



Required: At least five (5) years as a clinical/medical social worker


·        Experience on Maternal/Child Health units

·        Previous Case Management experience

Other Skills/Knowledge


·        For safety and quality reasons, must be able to read, write and communicate effectively in English with patients, visitors, vendors, and fellow members of the hospital team

·        Computer skills

Preferred: InterQual Criteria



Required: Commonwealth of Massachusetts Licensed Social Worker

Referred: Case Management certification



Neonate, Infant, Children, Adolescent, Adult, and Geriatric


Professional Commitment Requirements:  Keep abreast of developments in the field and/or licensure through continuing education, participation in professional organizations or a combination of both.

On-call:  N/A

Schedule requirements:  Based on department needs.

Travel requirements:   N/A



·        Reports to the Director of Case Management

·        Not responsible for supervising the work of others


As part of the Case Management team, this serves the dual roles of:


Case Management:


·        Utilizes the case management process to provide quality and safe patient care by identifying the specific needs of the patient and developing the plan of care for discharge with the patient.

·        Establishes a therapeutic relationship with the patient, the patient's family and significant others by involving them in each step of the care coordination process and accommodates factors that may influence the plan of discharge.

·        Collaborates with the multi-disciplinary healthcare team regarding the patient’s plan of care to promote the best possible outcomes and patient/family experience upon discharge.

·        Addresses the patient’s physical, emotional, cultural, and spiritual needs.

·        Performs all required documentation accurately, legibly and timely.

·        Appropriately follows the chain of command and adheres to hospital policies and procedures.

·        Greets patients.  Rounds on patients daily to educate and inform them regarding their plan of care.

·        To assess the daily case management workflow and optimize the team’s efficiency, gathers census information, reviews admissions, reconciles admissions, transfers and discharges against census and conducts hand-offs regarding patients when appropriate.

·        Reviews discharges to verify the required insurance approvals have been received.

·        Collaborates with the patient, patient’s family, insurance companies and the multi-disciplinary team to determine and coordinate the patient’s next level of care.

·        Patient care rounds with multi-disciplinary team to review the plan of care.

·        Reviews patient’s charts, conducts utilization reviews, ensures the physician’s order is appropriate for the level of care the patient meets and applies InterQual criteria to determine the level of care, medical necessity, and coverage of hospitalization.

·        Initiates the appropriate termination of benefits notice if the patient does not meet the hospital level of care criteria.  As appropriate, refers cases to physician utilization review vendor to establish observations vs. in-patient status. Completes a high risk assessment on any patient who meets the high risk criteria.

·        Documents and develops plan of care in preparation for discharge.

·        Collaborates with other healthcare facilities and external vendors to assist patients and patient families in setting up services to transition safely upon discharge to the next level of care.

·        Contacts insurance companies to obtain authorizations for hospital stays and levels of care upon discharge.


Social Work Services for Material Child Health Units and throughout the Hospital

·        Performs social work functions

·        Collaborates with other members of the health care team to evaluate patients' medical or physical condition and to assess client needs.

·        Investigates abuse or neglect cases and take authorized protective action when necessary.

·        Refers patient, client, or family to community resources to assist in recovery from mental or physical illness and to provide access to services such as financial assistance, legal aid, housing, etc.

·        Counsels patients to help them overcome dependencies, recover from illness, and adjust to life.

·        Counsels family members to assist them in understanding, dealing with, and supporting the client or patient

·        Advocates for patients to resolve crises

·        Collaborates with other healthcare facilities/organizations and other vendors to assist patients and patient families in setting up services to assist the patient financially, with transportation and to the next level of care.

·        Assists patients in accessing other financial resources including but not limited to charitable organizations, pharmaceutical companies and government agencies.

·        Completes a psycho-social assessment on each patient to guide the plan of care and to communicate to the multi-disciplinary team pertinent issues to consider.

·        Networks patients to other patients and resources realizing that patient outcomes improve when they know they are not alone in their issues and related challenges.


Part time, 24 hours

About Us

Beth Israel Lahey Health is an integrated system providing patients with better care wherever they are. Care informed by world-class research and education. We are doctors and nurses, technicians and social workers, innovators and educators, and so many others. All with a shared vision for what healthcare can and should be. We are committed to attracting, developing and retaining top talent. We strive to create a diverse and inclusive workplace that reflects the communities in which we work and serve. With a team approach to care, we encourage learning and growth at all levels and offer competitive salaries and benefits.

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