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About the Role

This role focuses on safeguarding and promoting the welfare of patients by providing social work assistance related to illness, disease, hospitalization, and life events. The position involves identifying, assessing, and coordinating cases, anticipating needs, and managing projects and processes using specialized knowledge. It is a senior-level role requiring advanced knowledge and independent work with limited supervision, potentially coaching lower-level professionals.

Responsibilities

Assesses/Screens patients for discharge planning needs within 24 hours of admission, and as needed.
Attends multidisciplinary huddles/discharge meetings to communicate, identify, and escalate discharge planning barriers timely.
Identifies patients’ goal 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 assessing potential impact to the discharge plan.
Informs the patient and clinical team of payor matters impacting admission, discharge, and post-acute transitions.
Identifies early in the admission complex discharge planning needs and hands off per local facility guidelines.
Ensures authorization for post-acute services are obtained in a timely manner.
Maintains timely documentation of all patient interactions including assessment, referral follow-up, and interventions.
Complies with all applicable State, Federal, and professional organization regulations.
Upholds standards of professional practice, including HIPAA and CMS discharge planning requirements.
Ensures 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 Ethics Committee for resolution.
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.
Takes responsibility for the care provided according to their scope of work ensuring completion.
Ensures assessment, care, and treatment are consistent with the specific age-related needs of the patient.
Completes psychosocial assessments and interventions with high-risk, complex patient populations.
Advocates for and mobilizes 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.
Recognizes the inherent worth of those served and 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 to be admitted patients and 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.
Experience in acute care hospital setting.
Certification in Case Management.

Skills

Ability to maintain confidentiality in all interactions.
Meets requirements for mandatory/continuing education and skills competency.
Ability to handle complaints/concerns in a prompt and courteous manner; 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, time management, and critical thinking skills.

Location

Normal office setting
Work from home
Community locations
Inpatient and/or outpatient clinic patient care setting

Work Type

Full-time

Experience Level

Senior level
Three (3) years of Social Work experience

Education Level

Master’s degree in Social Work

Benefits

Comprehensive Total Rewards package that supports your health, financial security, and career growth

About the Company

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.