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Beth Israel Lahey Health Care Manager Social Worker - Medicare in Wakefield, Massachusetts

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

Job Type:


Scheduled Hours:


Work Shift:

Day (United States of America)

Beth Israel Lahey Health Performance Network Medicare Shared Savings Program 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 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 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 Social Worker upholds the current standards of social work case management practice and reports to the Manager of Care Management, Medicare Shared Savings Program-ACO.

Job Description:

Essential Duties & Responsibilities (including but not limited to):

-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 obtaining advanced directives.

-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.

Leadership Competencies

-Demonstrates professional behavior by adhering to unit policies and procedures, practice guidelines specific to the setting and the National Association of Social Workers’ Code of Ethics.

-Demonstrates skills as a responsive team member.

-Demonstrates clinical leadership as evidenced by supporting research and development of care pathways.

-Demonstrates role of social worker as teacher and coach.

-Demonstrates ability to fulfill role in supporting the ACO in regulatory compliance as appropriate.

-Practices in accordance with applicable state and federal regulations, statutes, and laws.

Organizational Requirements:

-Maintains strict adherence to the Beth Israel Lahey Health (BILH) Confidentiality policy.

-Incorporates BILH Standards of Behavior and Guiding Principles into daily activities.

-Complies with all BILH Policies.

-Complies with behavioral expectations of the department and BILH.

-Maintains courteous and effective interactions with colleagues and patients.

-Demonstrates an understanding of the job description, performance expectations, & competency assessment.

-Demonstrates a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards.

-Participates in departmental and/or interdepartmental quality improvement activities.

-Participates in and successfully completes Mandatory Education.

-Performs all other duties as needed or directed to meet the needs of the department.

Minimum Qualifications:

Education: Masters in Social Work

Licensure, Certification & Registration: LICSW - Current Active, unrestricted Massachusetts Social Work License required.


-5 years medical or community based social work experience is preferred.

-Excellent clinical, interpersonal and communication skills. Must be able to work collaboratively with other healthcare professionals as well as independently. Experience working with the chronic, complex and/or behavioral health population in a physician management service organization is highly desirable.

-Must be proactive, assertive, and possess creative problem solving skills.

-Experience with Medicare population, managed care, ACO, medical home or integrated case management environment highly desirable.

-Must be proficient in computer skills, internet, information technology and electronic medical record use. Epic experience highly desirable.

Skills, Knowledge & Abilities:

  1. Demonstrates expert practice skills that include flexibility, priority setting, problem-solving, conflict resolution, negotiating and networking skills, decision making, work delegation and organization, and verbal / written communication skills.

  2. Demonstrates effective teaching techniques applying adult learning principles.

  3. Demonstrates ability to coordinate appropriate educational materials for patients and their support systems.

  4. Demonstrates sound knowledge bases and actions in the decision making process for designated patient populations.

  5. Excellent interpersonal and organizational skills.

  6. Knowledge base of psychosocial care, case management, social work, community resources and related regulations.

  7. Ability to manage and provide leadership to an interdisciplinary group.

FLSA Status:


As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more ( about this requirement.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled