Social Worker, Care Coordinator – Harbor Medical Associates – Norwell, MA


Working closely with high risk patients, the Ambulatory Clinical Social Work Care Coordinator is responsible for establishing, implementing, monitoring, and evaluating high quality, cost effective care plans within the context of Harbor’s developing Integrated Care Management Program (iCMP). iCMP at Harbor Medical Associates is a new initiative, based on an existing model at Brigham and Women’s HealthCare (BWHC) and across the Partners HealthCare System (PHS). iCMP leverages nurse and social work care coordinators to establish, implement, monitor and evaluate high quality, cost effective care plans for some of the sickest patients in our network. The iCMP team collaborates with patients, their families, and Primary Care teams to develop care plans.

The Clinical Social Worker is a key member of the iCMP 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. S/he will be expected to serve as the lead care coordinator for a panel of patients, while providing consultative support for other patients within iCMP who are primarily managed by a Registered Nurse Care Coordinator (RNCC). The Clinical Social Worker and RNCCs will be close partners in this model.

The Clinical Social Worker collaborates with the Care Team to enhance care across the continuum from outpatient to inpatient to post-acute care. The Clinical Social Worker meets the patient’s needs efficiently and expeditiously by continuously improving the patient’s experience and helping to ensure the institutional standards of high quality patient care. Through broad knowledge of clinical care, systems management and care coordination, the Clinical Social Worker evaluates, develops a plan of a care, and facilitates the trajectory of patient care.

The Clinical Social Worker is involved in the assessment and triage of patients and families, to ensure provision of appropriate, timely, and effective care. An initial bio-psychosocial assessment is conducted by the Clinical Social Worker independently and is then communicated with the patient’s primary care team. Care plans are developed in collaboration with the patient, family, and his/her Care Team. The Clinical Social Worker may provide direct intervention to patients and families and may work with the treating clinicians in primary care, psychiatry, psychology, or other disciplines, within and outside of the Partners Healthcare system.

The Clinical Social Worker remains knowledgeable about performance targets established via the iCMP Leadership Team and strives to achieve these goals. The Clinical Social Worker must have strong communication skills and must be able to engage easily with patients and their caregivers, members of the primary care team, and members of the iCMP team. This position requires a broad knowledge of clinical care and systems’ management and case management expertise. The position also requires prudent clinical judgment, knowledge of health care reimbursement, sound problem solving skills, independent thinking, excellent organizational and interpersonal skills, leadership, creativity, flexibility, teamwork, and the ability to multi-task.

  • Reviews and assists in triaging new iCMP patients with the PCP, RN Care Coordinator, and other members of the iCMP team, as appropriate.
  • Completes comprehensive bio-psychosocial assessment of patients to evaluate clinical needs, including but not limited to mental health/psychiatric history/emotional issues/coping style, understanding of illness/adjustment/compliance, barriers to care, cultural issues, abuse and/or neglect and domestic violence, and substance abuse. When abuse and/or neglect is/are suspected, the Clinical Social Worker files mandated reports as indicated by BWPO/Harbor Medical Associates policy and procedures.
  • Provides psycho-social assessment of families to determine family relationships/systems as they relate to the care of the patient, identifies family decision makers and caregivers, and evaluates the family’s understanding of illness and trajectory of care. Identifies family coping style, resources, and cultural issues.
  • Working with the Care Team, develops a comprehensive care plan, appropriately utilizing the menu of services available to patients. As indicated, provides direct and ongoing care management to select patients and / or refers to existing care management programs: insurance-based specialty case management programs, community resources, etc.
  • Ensures the timely implementation of the care plan and communicates critical elements of the plan and trajectory of care to the patient, family, and members of the care team.
  • Monitors the patient’s progress and comprehensive care plan with the aid of internal and external utilization and quality data and guidelines, documents and reports issues and system barriers. Intervenes to ensure the plan of care and services provided are patient focused, efficient and cost effective.
  • Establishes a consistent communication and reporting schedule for periodic contact with providers and patients to review patient status and progress toward goals.
  • Evaluates, coordinates, manages and documents timely and relevant information in patient electronic medical record and the program’s identified information technology tool (care management database) and communicates this information in a timely fashion
  • Identifies key barriers to care and the patient’s ability to manage their health and wellness through initial and ongoing assessments.
  • Communicates with other health care clinicians throughout the continuum about patient’s care, utilization, and follow up plans, e.g., inpatient facilities, ED Care Facilitators at BWHC, ED OBS Case Managers within the Care Progression Department at South Shore Hospital, inpatient Care Coordinators, post acute case managers, social workers, pharmacists, etc.
  • Provides/completes necessary iCMP assessments upon discharge from an inpatient admission
  • Employs a range of clinical interventions, such as, but not limited to, individual, group or family counseling. Provides caregiver/family counseling or support to promote family/caregiver cohesiveness and ability to provide care to the patient. Prepares patient and families for care transitions, including end-of-life care. Advocates on behalf of patients and families to gain access to services and resources. Refers patients to other providers and iCMP team members, as needed
  • Coordinates family/team meetings when appropriate
  • May, on occasion, provide consultation to practice staff regarding patients who are not part of the high risk program
  • Acts as a resources to the care team and works, on a case by case basis, to coach and mentor on techniques and approaches to managing psychosocial and substance abuse issues in a high risk, complex patient population and advocate for optimal outcomes
  • Collaborates with PCP and/or iCMP Manager and Medical Director regarding challenging patient situations, high priority patients, and over/under utilization of services and patient compliance with program
  • Attends and presents in formal and informal case reviews, seminars, program meetings and practice meetings. May participate in research projects. May initiate/implement psychosocial programs based on patient/family identified need.
  • Participates in regular meetings with iCMP Manager and Medical Director to review performance, patient volume, projects, outside professional activities, and upcoming goals to achieve
  • Performs other duties, as assigned.


  • Five years experience in the field of psychiatry, substance abuse, trauma, and/or community mental health services preferred
  • Clinical experience, understanding of, and comfort working with patients of all ages who suffer complex medical and psychiatric problems; ability to work the families/caregivers of such patients, and the ability to help patients and families understand and access the resources required to support care
  • Strong understanding of psychiatric and family system and ability to use this understanding to formulate succinct case summaries
  • Knowledge regarding end-of-life care
  • Demonstrated ability to be flexible and adapt to a complex, fast-paced medical environment
  • Current certification in Case Management preferred.
  • Telephonic case management experience preferred.
  • Experience with adult and geriatric patient populations preferred.
  • The Clinical Social Worker is housed within select primary care practices which may change based on patient selection.
  • Performs patient outreach, education, and recruitment during start up and then periodically as patient eligibility lists become refreshed.
  • Maintains membership in a care management organization preferred.

Job Type: Full-time

Pay: $25.00 – $40.00 per hour


  • Dental insurance
  • Employee assistance program
  • Health insurance
  • Paid time off
  • Retirement plan
  • Tuition reimbursement
  • Vision insurance


  • 8 hour shift
  • Day shift
  • Monday to Friday


  • Master’s (Preferred)


  • community mental health services: 5 years (Preferred)


  • Massachusetts LICSW (Preferred)

Work Location:

  • One location

Click Here To Apply

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