About this role
When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.
CLINICAL SOCIAL WORKER (MSW)
Job Description:
Job Profile Summary
Beth Israel Lahey Health and Mount Auburn Hospital are devoted to consistently promoting a culture of Wellbeing, Empathy, Collaboration, Accountability, Respect, and Equity as outlined in our organization's WE CARE values which can be reviewed here Mission, Vision & Values | Mount Auburn Hospital.
The Licensed Clinical Social Worker (LCSW) Case Manager is responsible for providing comprehensive psychosocial assessment, care coordination, discharge planning, and resource management for patients across the continuum of care. As a key member of the interdisciplinary healthcare team, the LCSW Case Manager assesses social determinants of health, identifies barriers to treatment and discharge, facilitates transitions of care, and advocates for patients and families to ensure safe, efficient, and patient-centered outcomes. This role combines advanced clinical social work practice with case management principles to address psychosocial, emotional, financial, environmental, and behavioral health needs that impact patient health and recovery. This role reports to the manager of the care transitions team.
Job Description
ESSENTIAL DUTIES & RESPONSIBILITIES (including but not limited to):
Clinical Social Work Practice
· Conduct comprehensive psychosocial assessments to identify patient and family strengths, needs, risks, and barriers to care.
· Evaluate the impact of medical, behavioral health, substance use, financial, cultural, and environmental factors on patient care and recovery.
· Provide crisis intervention, supportive counseling, grief counseling, and emotional support to patients and families.
· Assess for abuse, neglect, domestic violence, human trafficking, self-harm risk, and other safety concerns, initiating appropriate interventions and mandatory reporting as required.
· Assist patients and families in understanding illness, treatment plans, healthcare options, and community resources.
Case Management and Care Coordination
· Collaborate with physicians, nurses, care managers, therapists, and community providers to develop and implement individualized discharge and transition plans.
· Coordinate post-acute services including:
o Skilled nursing facilities
o Rehabilitation programs
o Home health services
o Hospice and palliative care
o Behavioral health treatment
o Substance use treatment programs
o Community-based support services
· Facilitate timely referrals to internal and external resources.
· Participate in interdisciplinary rounds and patient care conferences.
· Monitor progression toward discharge goals and identify barriers that may delay transitions of care.
Resource Management
· Connect patients and families with community resources and benefits, including:
o Medicaid and public assistance programs
o Housing resources
o Transportation services
o Food insecurity programs
o Financial assistance resources
o Elder services and long-term supports
· Assist patients in accessing insurance benefits and available social services.
· Advocate for equitable access to healthcare services and community supports.
Discharge Planning
· Develop comprehensive discharge plans that support safe transitions to the next level of care.
· Coordinate family meetings when complex psychosocial or discharge planning issues exist.
· Ensure patients and caregivers understand available resources and follow-up care recommendations.
· Collaborate with community providers to promote continuity of care and reduce avoidable readmissions.
Documentation and Compliance
· Maintain accurate, timely, and complete documentation in the electronic medical record.
· Document psychosocial assessments, interventions, care plans, discharge planning activities, and patient outcomes.
· Ensure compliance with:
o CMS Conditions of Participation
o Joint Commission standards
o State and federal regulations
o Hospital policies and procedures
o Social work ethical and professional standards
Quality and Performance Improvement
· Participate in quality improvement initiatives related to patient experience, length of stay, readmissions, and care transitions.
· Support department and organizational goals related to patient outcomes and population health.
· Contribute to process improvement activities and interdisciplinary committees.
QUALIFICATIONS:
Education Required:
· Master's Degree in Social Work (MSW) from a CSWE-accredited program.
Licensure Required:
· Licensed Clinical Social Worker (LCSW) in the Commonwealth of Massachusetts.
Experience Required:
· Minimum of two (2) years of post-licensure social work experience in a healthcare, hospital, behavioral health, rehabilitation, or care management setting.
Preferred:
· Acute care hospital experience.
· Experience in care transitions, utilization management, or discharge planning.
Certifications Preferred:
· Certified Case Manager (CCM)
· Accredited Case Manager (ACM)
KNOWLEDGE, SKILLS, and ABILITIES
· Strong knowledge of social work principles, ethics, and standards of practice.
· Understanding of healthcare systems, care coordination, and discharge planning processes.
· Knowledge of community resources, public assistance programs, and behavioral health services.
· Excellent crisis intervention and conflict-resolution skills.
· Ability to work effectively with culturally diverse populations.
· Strong communication, assessment, advocacy, and interpersonal skills.
· Ability to prioritize competing demands in a fast-paced clinical environment.
· Proficiency with electronic medical records and clinical documentation systems.
OTHER REQUIREMENTS:
· Consistently promote a culture of Wellbeing, Empathy, Collaboration, Accountability, Respect, and Equity as outlined in the organization's WE CARE values.
· Demonstrated commitment and actions to valuing diversity and contributing to an inclusive working and learning environment
- Frequently communicates with patients, families, healthcare providers, and community agencies.
- Ability to walk throughout patient care areas and attend meetings across the organization.
- Ability to sit, stand, and use standard office and computer equipment for extended periods.
- May be required to respond to patient emergencies and crisis situations.
Pay Range:
$36.00 - $48.45
The pay range listed for this position is the base hourly wage range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law. Compensation may exceed the base hourly rate depending on shift differentials, call pay, premium pay, overtime pay, and other additional pay practices, as applicable to the position and in accordance with the law.