Care Manager, LICSW

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Location: Wakefield, MA
Job ID: 170426-1A
Date Posted: Dec 3, 2021
Category: Clinical Professional

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Job Description

Welcome To

Welcome to the Beth Israel Lahey Health Performance Network (BILHPN). BILHPN is a clinically integrated network of physicians, clinicians, and hospitals committed to providing high-quality, cost-effective care to the patients and communities they serve, while effectively managing medical expense. Leveraging best practices in population health management and data analytics, BILHPN improves care quality and patient health outcomes across Beth Israel Lahey Health through population health initiatives. BILHPN brings together the expertise of more than 4,500 providers across Eastern Massachusetts who share a common goal to achieve success in a value-based delivery system. 

About the Job

BILHPN MSSP Care Management provides Complex Care Management programs to our Medicare At Risk population.  We are looking for experienced RNs and LICSW’s that demonstrate strong skills recognized in the Care Management Standards of Practice including patient identification and care planning. Additionally desired candidates will have effective knowledge / skills with serious illness conversations, utilization of Palliative Care Programs and cultural determinants of health.

The Care Manager, LICSW provides care management services to the BILHPN primary care physicians focusing on at-risk, high cost, and chronic/complex condition patient populations. The Care Manager, LICSW is a core member of the team, responsible for assessing and supporting the psychosocial status of assigned individuals.  Collaborates with the primary care team to develop care plans on their assigned patient population through care coordination, condition management education and community resource support. Responsibilities include working with physicians, patients, families, and the multidisciplinary team all settings to optimize quality and efficient outcomes; and decrease total medical expenses. The Care Manager, LICSW assesses, plans, implements, coordinates, monitors and evaluates options and services to meet the individual patient needs. This role works closely with the primary care provider and patient to develop collaborative care plans to improve self-management of chronic conditions utilizing evidence-based best practice standards to promote and enhance their physical and psychosocial functioning with attention to the social and emotional impact of illness and disability.

The Care Manager, LICSW upholds the current standards of social work case management practice, and reports to the Manager, Care Management at BILHPN.

The Care Manager’s Responsibilities are:

  • The Care Manager, LICSW supports the primary/specialty care physicians in population health management by focusing care coordination attention on the at risk population driving utilization and costs to improve efficiency, quality and patient satisfaction.
  • Engages physician and practice team in proactive patient management by addressing medical /psychosocial/functional health care needs, follow-up, and referrals. Utilizes a designated patient roster reports to review at risk population with providers to prioritize program enrollment, care planning, addressing prognosis and potential palliative/hospice care referrals.
  • Offers and coordinates free care consultation to patient/caregiver telephonically, to reinforce condition management education or assist with completion of health care proxy, advanced care planning, or community resource navigation.
  • Aims to improve the individual's 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 connect to social and community services.
  • Advocates for patient and families, responds to and facilitates resolution of patient questions and concerns.
  • Develops comprehensive care plans in collaboration with patient, physician and health care team based on evidence-based best practice for chronic condition management. Creates a patient-centered care plan that addresses problems /barriers and develops action plan relevant to obstacles in chronic condition management. Refers patients to appropriate community resources and support programs.
  • Serves as the central resource for the physicians and practice team for the Medicare ACO population functioning as navigator, coach, and condition manager for the targeted patient population. Collaborates with patients to facilitate healthy behaviors. Utilizes coaching to foster healthy lifestyle management. Helps patients to learn strategies and skills designed to stabilize symptoms and prevent condition progression.
  • Aims to improve the individual’s overall quality of life by supporting treatment goals, empowering them to be advocates for themselves and assisting them to obtain benefits, access to health care and connect to social and community services.
  • Advocates for patient and families, responds to and facilitates resolution of patient questions and concerns.
  • Reviews at risk patients with providers to understand drivers of cost, current treatment plan, future course and prognosis. Ensures advance directives and appropriate referrals are addressed, such as palliative/hospice, and makes recommendations for cost reduction alternatives whenever appropriate.
  • Seizes opportunities to reduce gaps in care by making recommendations for efficiency, quality and cost improvement. Understands organizational goals and accountability towards maximizing organization performance.
  • Conducts formal reassessments 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 care management and incorporates shared decision making in all patient interactions.



  • Current Active, unrestricted Massachusetts Social Work License required, LICSW preferred.
  • LCSW without independent licensure but with appropriate experience are encouraged to apply
  • A minimum of 2 years medical or community based social work experience.
  • Experience with Medicare population, managed care, ACO, medical home or integrated case management environment highly desirable.
  • Experience with electronic medical records desirable and proficient computer skills mandatory.


Full time, 40 hours per week

About Us

Beth Israel Lahey Health is dedicated to improving health and wellness and making a difference in the lives of our patients, their families and all members of the communities we serve.  Formed in March 2019, Beth Israel Lahey Health is a patient-centered, integrated care delivery system providing a continuum of services spanning academic, tertiary and community hospitals, dedicated orthopedic and psychiatric hospitals, primary and specialty care, community acute care, ambulatory care, behavioral services and home health.  Beth Israel Lahey Health Performance Network is a unified joint contracting and population health management organization, jointly governed by participating physicians and hospitals.

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