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Social Worker- Spanish Speaker: BWH Southern Jamaica Plain

Medicaid ACO
40 Hours
Day Shift

The Social Worker for the Medicaid Accountable Care Organization (ACO) is a key member of the Primary Care team, providing clinical services and overseeing the coordination of care for high risk, complex patients with significant utilization of medical and/or psychiatric services and facilities. 

The Social Worker for the Medicaid ACO will be expected to serve as the primary coordinator of patient care for a panel of patients, ensuring communication among providers and patient. The patients are predominantly covered by Massachusetts Medicaid and are part of the innovative Medicaid ACO strategy at Brigham and Women’s Hospital. 

The Social Worker for Medicaid ACO will be embedded in a BWH primary care practice and be responsible for establishing, implementing, monitoring, and evaluating high quality cost effective, patient-centered care plans.

The Social Worker for the Medicaid ACO collaborates with the interdisciplinary team in creating and improving the system of care, in determining which interventions have been most helpful, and in outlining the essential elements of these interventions so the team can develop a model that may be used by others. The Social Worker for the Medicaid ACO remains knowledgeable about performance targets.

The Social Worker for the Medicaid ACO will partner with key state and community agencies to manage patients. 

The Social Worker for the Medicaid ACO will work to support the practice-based population health manager.

This position requires a broad knowledge of clinical care and systems’ management, case management expertise, strong clinical judgment, health care reimbursement, excellent organizational and interpersonal skills, creativity, flexibility, and the ability to multi-task.  

This role is supported by 1 year of pilot funding, with potential for renewal.


Behavioral Health

Provides comprehensive psychosocial assessment of patients to evaluate the mental health/psychiatric history/emotional issues/coping style, understanding of illness/adjustment/compliance, barriers to care, cultural issues, interpersonal violence. Provides mandated assessments when abuse or neglect is suspected (child, disabled adult, elder). Files reports as indicated.

Meets with patients/families in person, virtually and/or provide interventions over the phone. Utilizes evidence based practice and national standards to manage high-risk patients in the community.

Provides short‑term crisis intervention counseling for patients as needed.

Continually assesses patient’s behavioral health status, and provide evidence based interventions and strategies to improve patient/family functioning and /or medical adherence.

Provides recommendation and coordination of external and/or urgent psychiatric/social resources based on assessment and collaboration with patient/family. 

Provides risk assessment and intervention as part of the interdisciplinary team, with emphasis on harm reduction.  When necessary, refers to and coordinates with appropriate emergency services.

Provides care management around psychosocial/behavioral health needs using an evidence-based collaborative care management approach.

Acts as the lead liaison between patient and psychiatrist and other key treatment providers for patients receiving care management.

Works and collaborates with the Clinical Director for the Medicaid and the BWPO Medicaid ACO team on program intervention and design.

Health Behavior

Provides clinical assessment with patients around chronic disease and health behavior self management obstacles. 

Provides health behavior interventions to support and increase patient/family self-efficacy that include, but are not limited to, health action plans, change interventions, and motivational and problem solving techniques that address obstacles to goals.

Care Management

Reviews and assists in triaging new patients with the PCP and other primary care team members, as appropriate.

Works to optimize the mental health of the high-risk medical and psychiatric patient population and to maintain these patients in the community, avoiding hospitalization when appropriate.

Improves patient and/or family understanding of and adjustment to the medical/psychiatric diagnoses to maximize benefits of medical/psychiatric intervention and enhance patient functioning throughout the course of illness. Ensures that the patient is involved in all phases of the patient care process.

Provides psycho education to patient/family regarding mental illness recovery and relapse. Works with patient/family to develop relapse prevention strategies.

Identifies resources as needed to encourage patient’s progress, and provides evidence based psychotherapeutic interventions to assist patient in accomplishing treatment goals. 

Conducts family meetings as needed to support patient progress, collaborates with various medical providers and/or additional service providers to coordinate care.

Works effectively as part of the interdisciplinary health care team, communicating regularly with the PCP, RNCC and other members of the patients care team through the continuum of care.

Monitors the patient’s progress and plan of care with the aid of internal and external utilization and quality guidelines. Identifies, documents and reports issues and system barriers. Intervenes as necessary and appropriate to ensure that the plan of care and services provided are patient focused, of high quality, efficient and cost effective.

Monitors patients in non-acute facilities in collaboration with the medical team.

Acts as a resource to staff and works on a case by case basis, to coach and mentor on techniques and approaches to management of psychosocial issues in a high risk population.

Exemplifies program teachings and acts as a role model for patients by practicing behaviors consistent with goals of the program.

Presents and/or discusses clinical work in formal and informal case reviews and seminars as indicated.

May participate in research projects.  May initiate/implement psychosocial programs based on patient/family identified need as indicated by the Medicaid ACO initiative.   Programs may be intermittent/informal or ongoing.  

Performs other duties as assigned.

Quality, Utilization Management: High Risk Psychosocial 

Intervenes with appropriate individuals/departments/agencies regarding delays in service that may have an impact on quality of patient care, length of stay or inappropriate patient admissions.

Interacts with home care, community agencies and facilities to ensure safe and timely patient care transitions

Negotiates follow‑up contact with patient/family, community agency or facility to evaluate the effectiveness of the patient care transitions and identifies problems in service delivery

Ensures coordination of the communication process with patient/family concerning the plan of care, including coordination of family meetings and warm handoffs.

Ensures that patient/family is involved in all phases of the care process to the greatest extent possible.

Maintains current knowledge of and identifies needs in service delivery within social, governmental, protective services and legal agencies.

Participates in data collection for departmental quality assessment activities in collaboration with the care coordination department.

Participates in quality assessment/improvement activities designed to evaluate the appropriateness and effectiveness of the service delivery system in which care coordination operates.

Ensures that the patient and family receive consistent information regarding all aspects of care.

Leadership, Teaching and Education:

Assesses patient/family learning needs, styles and readiness.  Educates patients/families based on treatment plan, identifies barriers to care, diversity issues and learning styles.

Mentors and may supervise students and staff.  May teach in Departmental and Hospital seminars, workshops and rounds.

Demonstrates expert social work clinical practice within the department and with interdisciplinary staff.  Provides education and consultation to interdisciplinary health care providers, social work staff and community on psychosocial issues for patients.

Demonstrates active, ongoing commitment to professional growth and development of self and creates an environment conducive to the professional growth of others.

Participates in Departmental and Hospital committees.  May participate in social work research.

Organizational/Administrative Skills:

Takes responsibility for own administrative duties, including timely and appropriate documentation in patient medical records, timely and accurate daily reporting of activities and Hospital’s scheduling systems, and accurate reporting of time worked.

Provides clinical documentation including psychosocial assessment, progress notes, and billing compliance (if appropriate).

Attends and participates in Staff Meetings and interdisciplinary meetings/rounds.

Professional Conduct:

Adheres to and fosters compliance with NASW Code of Ethics, and Department and Hospital clinical, quality, compliance and safety standards, policies and procedures.

Hospital-Wide Responsibility:

Works within legal, regulatory, accreditation and ethical practice standards relevant to the position and as established by BWH/Partners; follows safe practices required for the position; complies with appropriate BWH and Partners policies and procedures; fulfills any training required by BWH and/or Partners, as appropriate; brings potential matters of non-compliance to the attention of the supervisor or other appropriate hospital staff.


Education: Master’s of Social Work Degree from an accredited program required

Licensure: Current Massachusetts Licensed Certified Social Worker (LCSW) required.


  • Previous clinical social work experience in a hospital setting preferred.
  • Bilingual (English/Spanish) strongly required.


  • Clinical experience, understanding of, and comfort working with adults who suffer complex medical and psychiatric problems; ability to work with the families of such patients, and ability to help patients and families understand and access the resources required to support care.
  • Ability to provide rapid clinical psychosocial assessments and brief, short or long term treatment/management with individuals, families, couples and/or groups.
  • Advanced crisis intervention/treatment/management skills; strong assessment and treatment skills.
  • Differential diagnosis and treatment with all modalities
  • Competence in abuse/neglect/violence, trauma, grief loss and bereavement
  • Cultural sensitivity and demonstrated competency in age specific behaviors
  • Knowledge of specific medical/psychiatric illnesses, procedures and treatments
  • Excellent clinical social work assessment and crisis intervention knowledge and skills
  • Strong understanding of psychiatric and family system problems, and ability to use this understanding to formulate succinct case summaries.
  • Knowledge of community agencies/resources.  Ability to advocate/negotiate systems for/with patients and families.
  • Demonstrated ability to understand the role of social worker in a complex, fast-paced medical environment
  • Demonstrated ability to consult/teach
  • Demonstrated ability to communicate effective orally and in writing. Excellent interpersonal skills including negotiation skills necessary to collaborate within a multi-disciplinary team. 
  • Tolerance for ambiguity; analytical skills and computer literacy
  • A sense of humor. 


  • Social Workers provide clinical care in various settings: at the bedside, in treatment areas and offices; and in patient’s homes.
  • The Community Health Center operates 7 days per week. Hours and work schedule will be flexible to meet the needs of patients, families, hospital and staff.
  • Must be prepared to come in to work or stay at work during a hospital emergency.


  • Staff member must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served on his/her assigned areas.

EEO Statement

Brigham and Women’s Hospital is an Equal Opportunity Employer.  All qualified applicants will receive consideration for employment without regard to race, sex, color, religion, national origin, sexual orientation, protected veteran status, or on the basis of disability. Brigham and Women’s Hospital I CARE Standards

Primary Location: MA-Jamaica Plain-BWH Jamaica Plain Southern Jamaica Plain Health Center
Work Locations: BWH Jamaica Plain Southern Jamaica Plain Health Center 640 Centre St Jamaica Plain 02130
Job: Social Worker
Organization: Brigham & Women’s Hospital(BWH)
Schedule: Full-time
Standard Hours: 40
Shift Day: Job
Employee Status: Regular
Recruiting Department: BWH Southern Jamaica Plain Health Center

Job Posted: December 22, 2020

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