New

Complex Care Social Worker

Mass General Brigham (Enterprise Services)
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Jul 30, 2025
The Licensed Clinical Social Worker II (LCSW/LICSW) is a key clinical member of the High-Risk, High-Cost Complex Care Management Program, operating at the top of their license as part of a highly collaborative interdisciplinary team. This program is dedicated to preventing unnecessary emergency department (ED) visits and hospitalizations by delivering proactive, patient-centered care that improves health outcomes, reduces healthcare costs, and supports patients in achieving their personal health goals. The Social Worker brings expertise in behavioral health, crisis intervention, social determinants of health (SDOH), and patient advocacy, within an interdisciplinary care team consisting of: * Registered Nurses (RNs): Medical care management, disease education, and transitions of care. * Pharmacists: Medication reconciliation, polypharmacy management, and adherence support. * Non-Clinical Care Coordinators: Administrative support, appointment scheduling, and resource coordination. * Community Health Worker: * Operational Improvement Associate: Data analysis, documentation oversight, quality improvement, and tracking of key performance indicators (KPIs). The Social Worker plays a leadership role in behavioral health integration, social determinants of health barriers, and crisis intervention, ensuring that the care team keeps patients stable in the community and prevents avoidable ED visits and inpatient admissions. This role will conduct patient visits and check-ins utilizing all modes of intervention: face-to-face, video, telephone, home/community visits, and patient gateway. This role will require regular travel to practice sites, emergency departments, hospitals, and patient homes as needed, based on the care for the patient. Principal Duties and Responsibilities: Conducts comprehensive behavioral health assessments. Conducts in-depth behavioral health evaluations using validated tools such as (PHQ-9, GAD-7, CAGE, ACEs) to identify mental health concerns, and develops behavioral health care plans integrated with medical and social interventions. When appropriate, provide brief, evidence-based therapeutic interventions, including Motivational Interviewing (MI), Cognitive Behavioral Therapy (CBT)-informed techniques, and Solution-Focused Therapy. Also, offers psychoeducation on stress management, coping strategies, and behavioral activation to help patients manage anxiety, depression, or trauma. Provides substance use disorder support & harm reduction to include comprehensive SDOH assessments and interventions. Conducts comprehensive screenings to identify social barriers impacting health, including housing instability, food insecurity, transportation issues, and financial stressors. Works to reduce unnecessary behavioral health Emergency Department visits and behavioral health hospital admissions, by Identify high-risk patients using real-time ED visit alerts, hospital discharge data, and predictive analytics to provide early intervention and conducting outreach to patients with a history of frequent ED visits or inpatient stays, ensuring they have access to primary care, behavioral health support, and community resources. Focuses on crisis prevention and de-escalation by Providing early intervention for patients with escalating behavioral health or social crises, ensuring appropriate community-based support is in place, offering same-day or next-day behavioral health support for patients experiencing acute distress, avoiding the need for ED visits, and working with community behavioral health agencies, and law enforcement alternatives to divert patients from unnecessary ED use. Collaborate with primary care providers (PCPs), behavioral health specialists, urgent care clinics, and community mental health programs to ensure patients access lower-acuity care settings instead of the ED. Also, work with Pharmacists to resolve medication-related ED visits, such as withdrawal symptoms, medication side effects, or adherence challenges. 7. Provide post-hospitalization support by conducting post-discharge outreach within 24-48 hours to assess social, behavioral, and logistical barriers to recovery and identify patients at high risk for readmission and ensure they have intensive post-hospital support Works with each member of the care team to serve as the behavioral health and SDOH expert, ensuring medical, behavioral, and social care are seamlessly integrated. Provides patient education on substance use disorder and mental health concerns and assists clinical teams in the evaluation of a patient's need for behavioral health services. Able and willing to travel and meet with patients at practice locations, hospitals, emergency departments, and patient homes within a defined region of care. This is a hybrid role requiring travel and onsite work at least 4 days a week. The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Normal office working conditions. Travel will be required in this role, and it will be dictated based on patient clinical needs. With that in mind, you will be expected to perform duties across various locations, including patient homes, the ER, and outpatient clinics. On-site work is expected for at least 4 days a week at one of the sites listed above. In-person presence at Assembly Row will be required on a monthly basis for PHSO team meetings. *When not traveling, the expectation is that your work will be conducted remotely. Bachelor's degree in Social Work, Master's degree in Social Work, or Mental Health and Behavioral Health required. 2-3 years Behavioral Health, Medical Social work. 2-3 years of expertise in trauma-informed care, crisis intervention, and SDOH navigation required. Familiarity with HEDIS measures, NCQA case management documentation, and Medicaid/Medicare care models preferred Experience with an EHR, Epic preferred Actively contribute to a culture of teamwork, respect, and shared decision-making. Demonstrate reliability, accountability, and adaptability in fast-paced healthcare settings. Uphold ethical standards of practice, including confidentiality and informed consent. Adhere to organizational policies related to safety, infection control, and appearance. Maintain up-to-date knowledge through continuing education, certification, and professional development opportunities. Must be able to meet patients face to face in an office setting, community setting, or patient home. Ability to work effectively in a complex, fast-paced medical environment and multiple practice locations. Experience managing patients with multiple chronic conditions, high healthcare utilization, and complex psychosocial needs Must be comfortable with change, have an ability to adapt and pivot as part of continuous process improvement activities. Strong ability to work autonomously while supporting a multidisciplinary team. Knowledge, Skills, and Abilities Demonstrated knowledge of social work theories, principles, and ethical guidelines. Excellent communication and interpersonal skills to effectively engage with various populations and healthcare team members. Strong assessment, problem-solving, and critical-thinking abilities to address complex psychosocial challenges. Ability to maintain professional boundaries and confidentiality while providing compassionate care. Ability to work with individuals from various backgrounds and communities. Mass General Brigham Incorporated is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.