Job Profile Summary

​This role focuses on safeguarding and promoting the welfare of patients and can provide services if necessary.  In addition, this role focuses on performing the following Social Work duties: Provides social work assistance to patients and families relating to illness, disease, hospitalization and life events in all areas of service as a member of multi-disciplinary team and in liaison with community resources.  Responsibilities also include identification, assessment, and coordination of cases and anticipation of needs related to illness, hospitalization, finances, education, and home/community service.  A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs.  The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education.   A senior level role that requires advanced knowledge of job area typically obtained through advanced education and work experience.  Typically responsible for: managing projects / processes, working independently with limited supervision, coaching and reviewing the work of lower level professionals, resolving difficult and sometimes complex problems.

Job Overview

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.

Job Description

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.

Physical Requirements:

1. Normal office setting, work from home, and community locations.

2. Inpatient and/or outpatient clinic patient care setting.

3. Frequent sitting, occasional standing & walking, and lifting of 5-10 lbs.

4. Requires manual dexterity using fine hand manipulation to operate computer keyboard.

5. Requires ability to see computer screen and reports.

Skills & Abilities:

1. Ability to maintain confidentiality in all interactions.

2. Meets requirements for mandatory/continuing education and skills competency.

3. Ability to handle complaints/concerns in a prompt and courteous manner; escalates when necessary.

4. Builds and maintains positive, professional relationships with the healthcare team and community partners.

5. Maintains technical knowledge and skills of E.H.R, computer applications, and integrated software systems.

6. Strong observational, verbal, and written communication, time management, and critical thinking skills.

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:

based on full-time equivalent