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Social Worker, MSW, Complex Community Case Mgt Team

Be part of an exciting initiative at the Beth Israel Deaconess Hospital - Plymouth supported by the Health Policy Commission. The Health Policy Commission funds the Community Acceleration, Revitalization, & Transformation (CHART) Program.  Initiatives for this program include care coordination, integration and delivery transformation, with the goal of enhancing patient safety, providing access and coordinating care between hospital and community providers and organizations.


As part of an innovative, interdisciplinary, community case management team, you will assist with providing behavioral health and case management services to dual aged and dual disabled patients and their families in the community setting.

The right social work candidate will have behavioral health background, case management experience, and knowledge of community resources.  A passion for working with a complex patient population, the ability to work independently and as part of a cohesive team is essential.   


  • · Masters in Social Work from a CSWE accredited program
  • · Experience with case management, and solution focused interventions
  • · Experience working with interdisciplinary teams
  • · Preferred experience with substance abuse/mental health
  • · Knowledge of community resources and experience with resource securement
  • · Experience using an electronic health record and other software systems

 Principal Duties and Key Responsibilities:

  • · Function as an integral member of the community case management team, working with Medicare and dual eligible (aged & disabled) complex patients and families with behavioral health and/or psychosocial stressors
  • · Manage assigned patient caseload with appropriate intervention and ongoing follow-up
  • · Make home visits, as needed, to assess the patient's environment and psychosocial needs
  • · Provide consultation to the community case management team, including patient outreach and/or follow-up as indicated
  • · Function as a patient advocate to determine and identify patient needs
  • · Support a patient's plan of care through extensive knowledge of community resources
  • · Develop close working relationships with community organizations, e.g., Old Colony Elder Services, to promote collaboration and identification of program availability, e.g., assisting with the Mass Health application process, securing Patient Assistance Funds for pharmaceuticals, etc.
  • · Assist community patients seeking assistance with accessing detox; working collaboratively with colleagues and community based providers
  • · Work closely, and in a well-coordinated manner, with BID Plymouth colleagues and community based behavioral health providers to ensure patients and their families receive access to timely, high quality care and services, including follow up to ensure connection

 Overall Requirements:

  • · Participate in activities related to CHART Phase 2 and/or additional grant requirements such as internal and external collaboration meetings, trainings, and performance reporting
  • · Participate in team meetings, and the creation of integrated plan of care for patients
  • · Provide and maintain up to date documentation electronically, along with ongoing, interdisciplinary team communication
  • · Work to expand and enhance one's knowledge of integrated care, best case practice for improving health outcomes, patient satisfaction, decreasing health care costs
  • · Share clinical expertise with practice staff and other health disciplines to ensure continuity and quality of care