Geriatric Social Worker II

Mass General Brigham Social Worker PositionMass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.This is an exciting opportunity to join the Mass General Brigham Population Health department as a Social Worker within the GRACE (Geriatric Resources for Assessment and Care of Elders) program. The GRACE Social Worker will provide home-based geriatric assessment and care management for older adults aligned with Mass General Brigham's Primary Care Providers. This role is designed to proactively support vulnerable older adults, ensuring comprehensive, coordinated care that aligns with their goals and preferences.As part of this initiative, the GRACE Social Worker will play a key role in:Conducting in-home geriatric assessments in collaboration with a GRACE Nurse Practitioner.Developing and implementing individualized care plans using GRACE care protocols.Engaging patients and caregivers in psychosocial support, health education, and goals-of-care discussions.Coordinating care with primary care providers and the GRACE interdisciplinary team to optimize outcomes and reduce unnecessary hospital utilization.This role is an essential part of Mass General Brigham's commitment to improving care delivery for high-risk older adults through proactive, patient-centered management. The GRACE Social Worker will build strong, lasting relationships with patients—offering culturally responsive care, continuity, and education to help manage complex social and health conditions and promote maximum functioning.We are seeking a full-time, 40-hour Social Worker with weekly schedules consisting of 36 hours of clinical, patient-facing time, and 4 hours of administrative time. This will be a hybrid role with the expectation that the Social Worker will conduct home visits in the Boston/Boston Metro West area up to 2 days per week and work remotely for the remainder of the week.Key components of GRACE Team Care include:In-home assessments by a nurse practitioner and social worker team.Individualized care plans developed using GRACE protocols.Collaborative care planning with primary care physicians.Ongoing home-based care management and coordination.Weekly interdisciplinary team meetings including a geriatrician, pharmacist, and mental health liaison.Primary Responsibilities:Screening/Assessment: The GRACE Social Worker will provide initial and ongoing assessment of an individual's psychosocial needs.Treatment Planning/Goal Setting: It is the responsibility of the GRACE Social Worker, working with the GRACE Interdisciplinary Team, to develop and implement a comprehensive treatment plan of care with the older adult based on the assessment.Care Plan Development: The GRACE Social Worker should work with the GRACE Nurse Practitioner and GRACE Interdisciplinary Team to develop a care plan and communicate that plan to the patient, caregiver, and the primary care provider.Education/Health Promotion: The GRACE Social Worker will provide education about community resources, entitlement programs, health care benefits and Advance Directives/Living Wills.Advocacy: The GRACE Social Worker will advocate for older adults to ensure that they have access to all needed care and resources within the community.Collaboration: The GRACE Social Worker will work to create an atmosphere in which social workers build professional relationships with peers and colleagues in the GRACE Interdisciplinary Team.Supportive Counseling: The GRACE Social Worker will provide the individual and his or her family/caregivers with supportive counseling as needed.Crisis Intervention: The GRACE Social Worker will assess and intervene in any medical or psychiatric crises presented by the individual and participate in developing crisis management and safety plans to minimize the event of future crises.Non-Patient Care Responsibilities: The GRACE Social Worker will enter all patient/family contacts in the electronic record using appropriate formats and templates.Qualifications:Master of Social Work (MSW) from an accredited school of Social Work required.Driver's License required.2+ years of clinical experience in a medical setting required.1+ years' experience with geriatric patient population strongly preferred.Clinical licensure (LCSW, LICSW or LMHC) preferred.Additional Knowledge, Skills and Abilities:Demonstrates proficient clinical judgment and application of professional values and ethics. Integration of prior clinical experience into current practice. Demonstrates proficiency to formulate assessment of risks, crisis intervention, psychosocial assessments, treatment plans, and the documentation of both in a timely manner. Demonstrates sound clinical judgment and innovation in advocating for clients while maintaining professional boundaries. Demonstrates proficient working knowledge of internal and external resources and refers appropriately. Provides a range of evidence-based interventions. Ability to advocate, coordinate, and continuously communicate with treatment plans with patients, family and the interdisciplinary team. Incorporates social sensitivity. If appropriate, utilizes supervision and consultation regularly and appropriately. Actively seeks assistance with complex cases and situations in a timely manner. Engages in quality improvement projects, uses data to measure progress. Facilitate skill-based groups. Knowledge, understanding and ability to negotiate and work in a complex organization. Demonstrate capacity to effectively communicate findings with a broader audience.Additional Job Details (if applicable):Schedule and Work Model:Full time (40 hours) Monday through Friday consisting of 36 hours of clinical, patient-facing time and 4 hours of administrative time.Hybrid: Approximately 3-4 days at patient homes and approximately 1-2 virtual days dependent on patient needs. Home visits are conducted in Boston, MA.Reimbursed for mileage, tolls and parking.On remote workdays, employees must use a stable, secure, and compliant workstation in a quiet environment. Teams Video is required and must be accessed using MGB-provided equipment.Remote Type: HybridWork Location: 399 Revolution DriveScheduled Weekly Hours: 40Employee Type: RegularWork Shift: Day (United States of America)Pay Range: $ - $98,238.40/AnnualAt Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.