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Learn more about working at Lahey Hospital and Medical Center

Inpatient Social Work, Care Transitions

Burlington, Massachusetts

Organization Facility: Lahey Hospital and Medical Center Category: Social Services Job ID: JR46224 Date posted: 03/08/2024
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When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

Job Type:


Scheduled Hours:


Work Shift:

Evening (United States of America)

Inpatient Social Work, Care Transitions

Job Description:

Assessment and Planning:

As a member of the interdisciplinary care team, identifies high-risk psychosocial factors of patients/families that impact status and discharge planning.

  • Educates the care team on the impact of social drivers of health (SDOH) on medical treatment and care planning.
  • Develops a psychosocial assessment, and intervention plan regarding identified patient and family needs utilizing all available sources of information.
  • Participates in inter-disciplinary and inter-agency collaborative efforts to identify and coordinate care, treatment and post-acute care needs.
  • Psychosocial assessment includes social, economic, cultural, age-related, and behavioral factors.
  • Demonstrates competency in knowledge of community resources to address identified needs.
  • Provides crisis intervention and counseling services to assist patients and families with their emotional needs and adjustment to the medical episode.
  • Documents assessments, intervention plans, and outcomes that are consistent with departmental guidelines and Hospital policies.
  • Provides accurate, timely, and appropriate documentation of all social work assessments and interventions in the electronic medical record per regulatory policies and procedures (this says the same thing as the bullet above.We can eliminate the bullet above.)
  • Assesses and screens patients for interpersonal violence (child, adult, elder).Provides education and facilitates reporting by interdisciplinary team members per hospital policies.
  • Provides education and facilitates reporting by interdisciplinary team members with direct knowledge of patient condition and events of concern.
  • Screen and identify SDOH risk factors that contribute to readmission, such as inability to access medications, lack of transportation, insurance status, etc.

Care Coordination/Care Transitions
As a member of the Care Transitions, the inpatient social worker collaborates with care providers and third-party payors to ensure that all appropriate services and resources are utilized in a timely and efficient manner.

  • Actively participates in multidisciplinary rounds (MDRs) and care conferences on assigned units and assists with documenting all pertinent information in the medical record.
  • Establish her/himself as an integral part of the team and present each day in the units to which they are assigned.
  • Maintains timely communications with third-party payor representatives to identify discharge needs and available resources.
  • Seeks out members of the treating team to identify the most efficient/effective plan to progress care and offers to assist with the identification of resources to facilitate the plan of care.
  • Provides patient/support system education and resources regarding options for care and completes relevant referrals to health agencies, mental health facilities, counseling services, social agencies, post-acute care providers, and disease or condition-specific resources in an effective and timely manner based on the patient condition/needs to minimize delays in patient receipt of services.
  • Demonstrates expertise in facilitating end-of-life discussions and issues, including goals of care, hospice, and palliative care.
  • Demonstrates expertise in addressing advance directives, power of attorney, health care representative, and guardianship issues and serves as a resource to the interdisciplinary health care team consulting with Legal as needed.
  • Maintains working knowledge of in-house and community resources and awareness of legal/risk issues related to care planning.
  • Identify and utilize appropriate interventions to address barriers to care/discharge; locate resources; identify options and available supports; facilitate referrals and applications to government/community agencies; advocate for access to resources; coordinate referrals and/or placement plans; assist patient and family to emotionally prepare for transitions; prevent readmissions for non-medical reasons. Particular attention to high-risk, complex care patients.
  • May facilitate support and psycho-educational groups.
  • Facilitates communication with the patient/family.This covers both the clinical aspect of communication and the coordination of meetings.

Document evaluations and ongoing work in a timely and comprehensive fashion that meet departmental standards.

  • Utilize appropriate documentation templates for assessments, brief interventions and progress notes in EHR.
  • Initiate evaluation within 24-48 hours or one business day of the referral or consistent with departmental standards to respond the same day when possible.
  • Complete all appropriate forms within established time frames.
  • Complete departmental statistics within established timeframes.
  • Ensure care coordination needs of assigned patients are met, and there is adequate documentation in the patient’s medical record.
  • Ethics/Standards
  • Maintain patient confidentiality and complies with professional ethics according to professional (NASW) and department standards.


Master of Social Work degree from an accredited school of social work
State of Massachusetts licensure as an LCSW

Two years of healthcare social work/case management experience
CCM or ACM (Commission for Case Management or American Case Management Association)
NASW membership

FLSA Status:


As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more about this requirement.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled

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Why join Beth Israel Lahey Health?

If you’re looking for a career where you can make a difference and explore your potential, Beth Israel Lahey Health is the place you belong. Our system includes a network of hospitals, physician practices, outpatient centers, and other healthcare facilities and we offer a broad range of careers in direct patient care, environmental services, registration, finance and many other fields. We are focused on providing compassionate and personalized healthcare with a strong reputation for clinical excellence and research and offer diverse opportunities for career growth and development. Conveniently, we have many locations in communities across Eastern Massachusetts and Southern New Hampshire.

At Beth Israel Lahey Health, we see you for all that you are – your experience and your dreams. Explore our open opportunities and find out why so many have already chosen to join our team.

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