Geriatric Social Worker

Social Worker - Grace ProgramThis 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/AssessmentTreatment Planning/Goal SettingCare Plan DevelopmentEducation/Health PromotionAdvocacyCollaborationSupportive CounselingCrisis InterventionNon-Patient Care ResponsibilitiesQualifications: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 case s 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.Demonstrates capacity to effectively communicate findings with a broader audience.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: 3-4 days at patient homes and 1-2 virtual days dependent on patient needs. Home visits are conducted in the Boston and Boston Metro West area.Reimbursement for mileage, tolls and parking provided.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: $67,537.60 - $98,238.40/AnnualGrade: 7At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.EEO Statement:6010 Mass General Brigham Community Physicians, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran's Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at View phone number on click.appcast.io.Mass General Brigham Competency FrameworkAt 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.