Social Worker - Case Manager - Full Time Day shift - MelroseWakefield Hospital

The position, as part of the interdisciplinary team, assesses plans, advocates, and coordinates care from admission to discharge ensuring adherence to the Case Management Model.

Hours: 40 hours per week / Day Shift

Location; MelroseWakefield Hospital

Minimum Qualifications:

1. Master’s degree in Social Work.

2. Licensed Independent Clinical Social Worker (LICSW) or Licensed Clinical Social Worker (LCSW)

3. Three (3) years of Social Work experience.

3. Current Basic Life Support (BLS) Certification.

Preferred Qualifications:

1. Experience in acute care hospital setting

2. Certification in Case Management

Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.

1. Assesses/Screens patients for discharge planning needs within 24 hours of admission, and as needed, to ensure the plan is adequate to the patient’s clinical course and anticipated post-acute needs.

2. Attends multidisciplinary huddles/discharge meetings to communicate, identify, and escalate discharge planning barriers timely.

3. Upon admission, identifies patients’ goal for discharge and likelihood for post-acute needs. Educates patient/family/support system on the discharge plan to ensure understanding.

4. Considers Readmission and Social Determinants of Health risk factors assessing potential impact to the discharge plan.

5. Informs the patient and clinical team of payor matters impacting admission, discharge, and post-acute transitions.

6. Identifies early in the admission complex discharge planning needs. Hands off to the leader, Complex Care Manager, and/or Complex Care Committee per local facility guidelines.

7. Ensures authorization for post-acute services are obtained in a timely manner.

8. Maintains timely documentation of all patient interactions including assessment, referral follow-up, and interventions, as per Case Management protocols/standard work practices.

9. 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.

10. Identifies and reports ethical situations to leader(s) and Ethics Committee for resolution as per local facility guidelines.

11. Supports the patient/family regarding Healthcare Proxy/advance directives and/or verifying a surrogate decision maker.

12. Delegates, guides, and directs unlicensed Case Management team member tasks. Takes responsibility for the care provided according to their scope of work ensuring completion. (e.g., Regulatory letter delivery)

12. The assessment, care, and treatment will be consistent with the specific age-related needs of the patient including neonatal/infant, child, adolescent, adult, and geriatric adult patients.

13. Completes psychosocial assessments and interventions with high-risk, complex patient populations advocating for and mobilizing resources to meet identified needs.

14. Provide 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.

15. Recognizes the inherent worth of those served and advocates for patient empowerment to make autonomous healthcare decisions.

16. Identifies and intervenes with at-risk patients to prevent readmission, social admissions, reduce unnecessary emergency room visits, and improve patient outcomes.

17. Identifies risk factors for potential crisis intervention needs related to clinical diagnosis, prognosis, Social Determinants of Health, and/or patient/family dynamics.

18. Coordinates and implements safe discharge plans in collaboration with the patient/family and the interdisciplinary team.

19. Identifies and provides community resources to ensure a safe and coordinated transition of care. 20.

20. Completes admission assessments and/or screenings on to be admitted patients and per regulatory requirements.

21. Serves as preceptor, mentor, and case management resource to other co-workers as needed/assigned.

About Melrose/Wakefield Hospital

Melrose/Wakefield Hospital and Lawrence Memorial Hospital of Medford are two campuses with one community in mind: the people of north suburban Boston. Melrose/Wakefield Hospital and Lawrence Memorial Hospital are distinguished by the range of high-quality clinical care and services. Our teams welcome everyone with hospitality and humanity. We 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 many local health programs throughout our service area and participation in partnerships with community agencies and events, and education programs in more than 10 communities to support the wellness and health of our residents.

At Tufts Medicine, we want every individual to feel valued for the skills and experience they bring. Our compensation philosophy is designed to offer fair, competitive pay that attracts, retains, and motivates highly talented individuals, while rewarding the important work you do every day.

The base pay ranges reflect the minimum qualifications for the role. Individual offers are determined using a comprehensive approach that considers relevant experience, certifications, education, skills, and internal equity to ensure compensation is fair, consistent, and aligned with our business goals.

Beyond base pay, Tufts Medicine provides a comprehensive Total Rewards package that supports your health, financial security, and career growth—one of the many ways we invest in you so you can thrive both at work and outside of it.

Pay Range: