Medical Social Worker

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Location: Beverly, MA
Job ID: 175575-1A
Date Posted: Jun 20, 2022
Category: Clinical Professional

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Job Description

Welcome To

Welcome To Beth Israel Lahey Health at Home. Our team provides high-quality home care and hospice services by partnering with physicians, hospitals and skilled nursing facilities to provide specialized care to patients in the comfort of their own home. Our team of nurses, therapists (physical, occupational, and speech), medical social workers, and home health aides work together to devise and implement a compassionate care plan that is expressly tailored for each patient.

About the Job

As a member of the care coordination team, the Medical Social Worker coordinates patient care by providing clinical, psychosocial, financial planning and care coordination services to patients/families whose psychosocial or environmental conditions inhibit the success of the patients' treatment plans, with the emphasis on community health education/experience. The medical social worker builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities in accordance with home care regulations and payer guidelines.


  Essential Duties & Responsibilities including but not limited to:

Patient Care

  1.  Assumes responsibility to coordinate patient care for assigned caseload and serves as an expert on, and as a liaison to community resource programs. Accepts accountability for patient satisfaction scores and quality of care outcome measure results.
  2. Completes and documents an initial assessment of patient and family to determine home care needs. Provides a complete assessment and history of current and previous illness(es). Develops a patient-specific plan of care, which establishes goals based on identifying the patient's/family's psychosocial, financial or legal concerns that affect patient care management, and interacts with patient/family/interdisciplinary team to facilitate the patient care process.
  3. Initiates the plan of care and makes necessary revisions as patient status and needs change in collaboration with the patient’s MD.
  4. Counsels the patient and family in meeting nursing and other discipline related needs. Improves patient and/or family understanding of and adjustment to the medical diagnosis to maximize benefits of medical intervention and enhance patient/family functioning throughout the course of illness. Ensures that the patient/family are involved in all phases of the patient care process.
  5. Respects and supports patient and family’s cultural beliefs and values, individual needs, health goals and treatment preferences.
  6. Identifies and utilizes appropriate community resources to optimize patient outcomes. Provides liaison and referral services to community agencies. Provides health care instructions to the patient as appropriate per assessment and plan of care.
  7. Manages episode of care in accordance with evolving medical social worker needs and continued eligibility for services.
  8. Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient.


  1. Communicates with the physician regarding the patient’s needs and reports any changes in the patient’s condition; obtains/receives physician’s orders as required.
  2. Attends regular case conferences and team meetings per Clinical Manager and as needed.
  3. Communicates with others on the care team and community providers to coordinate the care plan (i.e. Insurance case managers, high risk case managers, elder services, protective service, etc).
  4. Practices confidentiality principles set by the agency and federal HIPAA guidelines.


Minimum Qualifications:


  • Holds a minimum of a Master’s degree from a school of social work accredited by the Council on Social Work Education.
  • Minimum of one year of social work experience in a health care setting.

Licensure, Certification & Registration:

  • Holds a current LCSW, and is licensed to work in Massachusetts. 
  • Current Massachusetts Licensed Independent Clinical Social Worker (LICSW) preferred.
  • Has an active American Health Association BLS. If no American Heart Association BLS the employee must complete an annual BILHAH BLS Competency. No other forms of BLS will be accepted.


  • Minimum of one year of social work experience in a health care setting, previous home care preferred.

Skills, Knowledge & Abilities: 

  • Demonstrates excellent observation and problem solving/critical thinking skills.
  • Well-developed verbal and written communication skills; essential computer skills to work with EMR.
  • Must be a licensed driver with an automobile that is insured in accordance with state or organization requirements and is in good working order.
  • Self-directed and able to work with minimal supervision.
  • Shows strong ability to organize and prioritize workload independently.




Physical Requirements

Physical Requirements and Environment:

Mental and Visual Attention:

  • This position requires a high degree of mental and visual concentration.

Physical Exertion:

  • Nature of work requires lifting or moving medium weight (over 20 and up to 75 pounds).
  • Flow of work and nature of duties require average manual coordination.
  • Responsibilities require average range of motion.
  • Performance of duties allows for variation in positioning and tasks.
  • Responsibilities require frequent repetitive motion.

Working Conditions:

  • Working conditions include continuous exposure to elements such as odor, noise, dust, chemicals, teperature extremes or airborne pathogens.

Exposure to Hazardous Materials:

  • Performance of duties frequently involves exposure to hazardous materials. (Biohazardous).

Patient Care Conditions:

  • Responsibilities entail exposure to blood and bodily fluids; standard precautions must be used.
  • Incumbent must be continuously prepared to prevent a patient fail.

Sensory Requirements:

  • Performance of duties requires the ability to discern and identify colors.
  • Performance of duties requires the ability to discern sharp from dull and hot from cold.
  • Performance of duties requires the ability to hear soft and loud noises.

This position has a direct impact upon health outcomes of the patient.

Organizational Requirements:

  • Maintain strict adherence to the Continuing Care Confidentiality policy.
  • Incorporate Continuing Care Standards of Behavior and Guiding Principles into daily activities.
  • Comply with all Continuing Care Policies.
  • Comply with behavioral expectations of the Continuing Care Division.
  • Maintain courteous and effective interactions with colleagues and patients.
  • Demonstrate an understanding of the job description, performance expectations, and competency assessment.
  • Demonstrate a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards.
  • Participate in departmental and/or interdepartmental quality improvement activities. 
  • Participate in and successfully complete Mandatory Education.
  • Perform all other duties as needed or directed to meet the needs of the department.