LICSW Care Manager ACO

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

Beth Israel Lahey Health Performance Network Masshealth ACO (BILHPN-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. BILHPN-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 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.

Utilizing medical management techniques the Social Worker supports the ACO in avoiding hospitalization when possible, shortening unavoidable hospital stays, and reducing the 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 the quality and patient experience of care while eliminating unnecessary costs for patients.

Working with the 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 Care Manager LICSW's Responsibilities Are:

• 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 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, 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 the 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

Qualifications

• LICSW, Masters in Social Work
• Current Active, unrestricted Massachusetts Social Work License required.

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.