Social Worker - Case Manager Full Time / Day Shift

About the Role

As part of the interdisciplinary team, this position assesses, plans, advocates, and coordinates care from admission to discharge, ensuring adherence to the Case Management Model at MelroseWakefield Hospital.

Responsibilities

• Assesses/screens patients for discharge planning needs within 24 hours of admission and as needed to ensure the plan aligns with the patient’s clinical course and anticipated post-acute needs.
• Attends multidisciplinary huddles/discharge meetings to communicate, identify, and escalate discharge planning barriers in a timely manner.
• Identifies patients’ goals for discharge and likelihood for post-acute needs upon admission.
• Educates patient/family/support system on the discharge plan to ensure understanding.
• Considers readmission and Social Determinants of Health risk factors when assessing potential impact to the discharge plan.
• Informs the patient and clinical team of payor matters impacting admission, discharge, and post-acute transitions.
• Identifies complex discharge planning needs early in the admission and hands off to the leader, Complex Care Manager, and/or Complex Care Committee per local facility guidelines.
• Ensures authorization for post-acute services is obtained in a timely manner.
• Maintains timely documentation of all patient interactions, including assessment, referral follow-up, and interventions, as per Case Management protocols and standard work practices.
• Complies with all applicable State, Federal, and professional organization regulations.
• Upholds standards of professional practice, including HIPAA and CMS discharge planning requirements, ensuring respect of patient rights, choices, and understanding of skilled care criteria and post-acute care levels.
• Adheres to all state-mandated reporting guidelines.
• Identifies and reports ethical situations to leader(s) and the Ethics Committee for resolution as per local facility guidelines.
• Supports the patient/family regarding Healthcare Proxy/advance directives and/or verifying a surrogate decision-maker.
• Delegates, guides, and directs unlicensed Case Management team member tasks, ensuring completion according to their scope of work (e.g., regulatory letter delivery).
• Completes psychosocial assessments and interventions with high-risk, complex patient populations, advocating for and mobilizing resources to meet identified needs.
• Provides case intervention for child abuse/neglect, adult abuse/neglect, domestic violence, sexual assault, guardianship, adoption, and other identified at-risk patients as consulted and/or assigned.
• Advocates for patient empowerment to make autonomous healthcare decisions.
• Identifies and intervenes with at-risk patients to prevent readmission, social admissions, reduce unnecessary emergency room visits, and improve patient outcomes.
• Identifies risk factors for potential crisis intervention needs related to clinical diagnosis, prognosis, Social Determinants of Health, and/or patient/family dynamics.
• Coordinates and implements safe discharge plans in collaboration with the patient/family and the interdisciplinary team.
• Identifies and provides community resources to ensure a safe and coordinated transition of care.
• Completes admission assessments and/or screenings on patients to be admitted per regulatory requirements.
• Serves as preceptor, mentor, and case management resource to other co-workers as needed/assigned.

Requirements

• Master’s degree in Social Work.
• Licensed Independent Clinical Social Worker (LICSW) or Licensed Clinical Social Worker (LCSW).
• Three (3) years of Social Work experience.
• Current Basic Life Support (BLS) Certification.

Preferred Qualifications

• Experience in an acute care hospital setting.
• Certification in Case Management.

Skills & Abilities

• Ability to maintain confidentiality in all interactions.
• Meets requirements for mandatory/continuing education and skills competency.
• Ability to handle complaints/concerns promptly and courteously; escalates when necessary.
• Builds and maintains positive, professional relationships with the healthcare team and community partners.
• Maintains technical knowledge and skills of E.H.R, computer applications, and integrated software systems.
• Strong observational, verbal, and written communication skills.
• Strong time management and critical thinking skills.

Physical Requirements

• Normal office setting, work from home, and community locations.
• Inpatient and/or outpatient clinic patient care setting.
• Frequent sitting, occasional standing and walking, and lifting of 5-10 lbs.
• Requires manual dexterity using fine hand manipulation to operate a computer keyboard.
• Requires ability to see computer screen and reports.

Benefits

• Competitive salaries and benefits.
• 403(b) retirement plan with hospital match.
• Opportunities for growth.
• Tuition reimbursement.

Schedule

40 hours per week / Day Shift

Pay

The base pay range reflects the minimum qualifications for the role. Individual offers are determined using a comprehensive approach that considers relevant experience, certifications, education, skills, and internal equity. Pay Range: Competitive and commensurate with experience.

About Melrose/Wakefield Hospital

Melrose/Wakefield Hospital and Lawrence Memorial Hospital of Medford are two campuses serving the north suburban Boston community. Our teams focus on reducing health disparities through 40+ local health programs across a system of hospitals, urgent care locations, outpatient services, and community physicians. Core to our values, Melrose/Wakefield Hospital’s commitment to community is demonstrated by our participation in partnerships with community agencies, events, and education programs in more than 10 communities to support wellness and health.