Clinical Social Worker

Site: Mass General Brigham Community Physicians, Inc. Mass 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. Job Summary The Licensed Clinical Social Worker (LICSW) is a key clinical member of the High-Risk, High-Cost Complex Care Management Program, operating at the top of their license as part of a highly collaborative interdisciplinary team. This program is dedicated to preventing unnecessary emergency department (ED) visits and hospitalizations by delivering proactive, patient-centered care that improves health outcomes, reduces healthcare costs, and supports patients in achieving their personal health goals. The Social Worker brings expertise in behavioral health, crisis intervention, social determinants of health (SDOH), and patient advocacy within an interdisciplinary care team consisting of: Registered Nurses (RNs): Medical care management, disease education, and transitions of care. Pharmacists: Medication reconciliation, polypharmacy management, and adherence support. Non-Clinical Care Coordinators: Administrative support, appointment scheduling, and resource coordination. Community Health Worker. Operational Improvement Associate: Data analysis, documentation oversight, quality improvement, and tracking of key performance indicators (KPIs). The Social Worker plays a leadership role in behavioral health integration, social determinant of health barriers, and crisis intervention, ensuring that the care team keeps patients stable in the community and prevents avoidable ED visits and inpatient admissions. This role will conduct patient visits and check-ins utilizing all modes of intervention: face-to-face, video, telephone, home/community visits, and Patient Gateway. This role will require regular travel to practice sites, emergency departments, hospitals, and patient homes as needed based on the care for the patient. Primary Responsibilities: Conducts comprehensive behavioral health assessments. Conducts in-depth behavioral health evaluations using validated tools such as PHQ-9, GAD-7, CAGE, and ACEs to identify mental health concerns, and develops behavioral health care plans integrated with medical and social interventions. When appropriate, provides brief, evidence-based therapeutic interventions, including Motivational Interviewing (MI), Cognitive Behavioral Therapy (CBT)-informed techniques, and Solution-Focused Therapy. Also offers psychoeducation on stress management, coping strategies, and behavioral activation to help patients manage anxiety, depression, or trauma. Provides substance use disorder support and harm reduction, including comprehensive SDOH assessments and interventions. Conducts comprehensive screenings to identify social barriers impacting health, including housing instability, food insecurity, transportation issues, and financial stressors. Works to reduce unnecessary behavioral health emergency department visits and behavioral health hospital admissions by identifying high-risk patients using real-time ED visit alerts, hospital discharge data, and predictive analytics to provide early intervention. Conducts outreach to patients with a history of frequent ED visits or inpatient stays, ensuring they have access to primary care, behavioral health support, and community resources. Focuses on crisis prevention and de-escalation by providing early intervention for patients with escalating behavioral health or social crises, ensuring appropriate community-based support is in place, offering same-day or next-day behavioral health support for patients experiencing acute distress, avoiding the need for ED visits, and working with community behavioral health agencies and law enforcement alternatives to divert patients from unnecessary ED use. Collaborates with primary care providers (PCPs), behavioral health specialists, urgent care clinics, and community mental health programs to ensure patients access lower-acuity care settings instead of the ED. Also works with pharmacists to resolve medication-related ED visits, such as withdrawal symptoms, medication side effects, or adherence challenges. Provides post-hospitalization support by conducting post-discharge outreach within 24-48 hours to assess social, behavioral, and logistical barriers to recovery, identify patients at high risk for readmission, and ensure they have intensive post-hospital support. Works with each member of the care team to serve as the behavioral health and SDOH expert, ensuring medical, behavioral, and social care are seamlessly integrated. #J-18808-Ljbffr