Location: Wakefield, MA
Job ID: 174936-1A
Date Posted: Mar 28, 2022
Category: Clinical Professional
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:
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.