Ambulatory Social Work Case Manager

12-Dec-2024

Ambulatory Social Work Case Manager

University Health Services

67603BR

Position Description

Assists HUHS patients and their families in coordinating medical, social, emotional, insurance, and vocational issues related to injury or illness. Conducts psychosocial assessments, either in-person or telephonically, in order to develop a comprehensive out-patient care plan that guides work with patient. Collaborates with physicians, nurses, support staff, community agencies, and other health care professionals to implement safe, effective, and timely patient care. Communicates with treating clinicians on areas of concerns and provides clinical updates to clinicians on a regular basis. Provides timely and appropriate documentation in patient's electronic medical record. Participates in assuring that HUHS is in the forefront of applying Case Management principles. Participates in achieving the goal of cost effective, high quality, continuous care to patients; communicates effectively with clinicians, patients, and team leader to achieve this goal. Utilizes team leader as appropriate for clinical consultation and to apprise of legal, ethical, risk issues that may affect the patient, family, or health services. Maintains quality assurance and improvement activities in compliance with HUHS standards. Assists in development of reports and resources required by other departments. 
Duties and Responsibilities:

• Assumes responsibilities of an active caseload, including following patients throughout the continuum of care. 
• Educates patients/families about health insurance processes and when appropriate benefits. Directs patients/families where to learn more about health insurance benefits. 
• Educates patients/families/caregivers as to trajectory of certain disease processes and level of support/care needed throughout disease process. 
• Assists in maintaining a Quick Reference Resource Guide. 
• Actively participates in project development.  Collaborates with manager to implement, evaluate, and support programs to maximize utilization of available resources. 
• Identifies areas of improvement; recommends and implements solutions. 
• Educates HUHS staff about Care Coordination’s scope of service and how to utilize HUHS case managers as resources. 
• Ensures the department maintains effective communication with other HUHS Departments. 
• Acts as a liaison between patients and HUHS to assist in coordinating follow up services. 
• Educates patients/families about non-skilled services for patients when necessary. Assists in arranging for these services when patients/families allow. 
• Assess quality of care of Home Care providers as well as responsiveness. Addresses areas of concerns with manager to ensure optimal quality of care for patients. 
• Evaluates utilization and effectiveness of Home Care provider network.  
• Communicates with primary care clinician, patient, and home care provider to ensure medically necessary services. Regularly communicates with patients requiring post- discharge service to assess patient satisfaction and that appropriate services are in place. 
• Participates in/attends HUHS committees/work groups when appropriate. 
• Participates in/attends IM Team Meetings and daily huddles. 
• Promotes effective communication with hospitals and their departments. Educates them to resources available at Harvard University Health Services. 
• Educates patients and families regarding Advance Directives and assists patients and families in completing Advance Directives. 
• Assists HUHS patients and their families coordinate medical, social, emotional,     insurance, and vocational issues related to injury or illness.   
• Provides pre-operative outreach and assessment to identified student athletes.  
• Provides a clinical assessment either telephonically or as appropriate in person to assess patient’s needs and perception of their health status. 

Basic Qualifications

• Master’s degree or equivalent work experience required
• Minimum of 5 years’ relevant work experience

Additional Qualifications and Skills

• Knowledge of Microsoft Office Suite, intermediate Excel skills
• Excellent organizational, analytical, problem solving and interpersonal skills
• Ability to work independently and as part of a team.
• Familiar with care needs of medically complex young adult, adult, and geriatric populations.
• Ability to provide a high level of customer service to patients, staff, and external customers in a professional, service-oriented, respectful manner in using skills in active listening and problem solving. Excellent organizational, analytical, problem solving and interpersonal skills. 

Certificates and Licenses

• Licensed Independent Clinical Social Worker with current Massachusetts license

Physical Requirements

All Harvard University Health Services (HUHS) staff and staff affiliates are considered Health Care Workers and as a condition of employment must provide documentation of the following:  

• Letter of good health from your personal health care provider.  
• TB skin test (within past 3 months) or, if known skin test positive, documentation of previous chest x-ray, information about any past treatment.  
• Documentation of immunity (positive antibody titers) for Measles, Mumps, Rubella and Varicella.  
• Proof of appropriate past immunization for Measles, Mumps, Rubella and Varicella. 
• Hepatitis B vaccine series – required for staff with possible exposure to blood or blood borne pathogens.  
• A current Flu vaccine (this season) and Covid vaccines to include the Primary series and Bivalent Booster.  

The required medical documentation/medical clearances can often be obtained by contacting your Pediatrician, PCP, medical provider. Titers, TB Skin testing can be performed by appointment at Occupational Health facilities. 

HUHS continues to place the highest priority on the health, safety and wellbeing of its faculty, staff and students, as well as the wider community. Being up to date with COVID vaccination, annual flu vaccination and other required medical vaccinations and documentation are required as a condition of employment at HUHS. You may claim exemption from the vaccine requirements for medical or religious reasons. 

Working Conditions

• Travel may be required
• May be required to work nights and weekends

Additional Information

Duties and Responsibilities continued:

• Assists HUHS patients and their families coordinate medical, social, emotional,     insurance, and vocational issues related to injury or illness.   
• Educates patients and families regarding Advance Directives and assists patients and families in completing Advance Directives. 
• Promotes effective communication with hospitals and their departments. Educates them to resources available at Harvard University Health Services. 
• Participates in/attends IM Team Meetings and daily huddles. 
• Participates in/attends HUHS committees/work groups when appropriate. 
• Communicates with primary care clinician, patient, and home care provider to ensure medically necessary services. Regularly communicates with patients requiring post- discharge service to assess patient satisfaction and that appropriate services are in place. 
• Evaluates utilization and effectiveness of Home Care provider network.  
• Assess quality of care of Home Care providers as well as responsiveness. Addresses areas of concerns with manager to ensure optimal quality of care for patients. 
• Educates patients/families about non-skilled services for patients when necessary. Assists in arranging for these services when patients/families allow. 
• Acts as a liaison between patients and HUHS to assist in coordinating follow up services. 
• Ensures the department maintains effective communication with other HUHS Departments. 
• Educates HUHS staff about Care Coordination’s scope of service and how to utilize HUHS case managers as resources. 
• Identifies areas of improvement; recommends and implements solutions. 
• Actively participates in project development.  Collaborates with manager to implement, evaluate, and support programs to maximize utilization of available resources. 
• Assists in maintaining a Quick Reference Resource Guide. 
• Educates patients/families/caregivers as to trajectory of certain disease processes and level of support/care needed throughout disease process. 
• Educates patients/families about health insurance processes and when appropriate benefits. Directs patients/families where to learn more about health insurance benefits. 
• Provides supportive counseling to patients and families to enhance coping skills and resolve concerns. 
• Provides supportive counseling to patients and families considering changes in living situations or managing changes related to a medical condition. 
• Collaborates when appropriate with BCBS MA Nurse Case Manager in case management of HUSHP/HUGHP patients with complex medical and psychosocial needs. 
• Develops a comprehensive treatment plan. Monitors and assesses appropriateness of treatment plan and makes appropriate modifications as necessary. 
• Communicates with PCP or treating clinician on areas of concern in addition to ongoing updates on clinical progress. 
• Reports incidences of suspected abuse and neglect of children, elders, and individuals with disabilities to appropriate designated state agency. 
• Organizes and participates in patient case conferences as needed Provides timely, appropriate, comprehensive clinical documentation in patient's electronic medical record. 
• Gives appropriate notice to manager when unexpected circumstances call for staff member to be away
• Participates in the orientation of new staff members. 
• Identifies own learning needs and requests assistance from others when needed. 
• Works independently, as well as collaboratively, with all members of the health care team. 
• Treats patients with dignity, respect, and compassion. 
• Provides prompt care/service and behaves sensitively in all interactions. 
• Utilizes team leader as appropriate for clinical consultation and to apprise of legal, ethical, risk issues that may affect the patient, family, or health services.  

Work Format Details

This position is based primarily on-campus, in Massachusetts. This may include in-person during emergency situations (if applicable). Additional details will be discussed during the interview process. Certain visa types may limit work location. Individuals must meet work location sponsorship requirements prior to employment.

About Us

Harvard University Health Services (HUHS) is a campus-based health care organization devoted exclusively to members of the Harvard community. Our work includes multi-specialty ambulatory medical care, behavioral and mental health services, and campus public health. HUHS also manages two self-funded health insurance plans, the Harvard University Group Health Plan (HUGHP, for university employees and dependents) and the Student Health Insurance Plan (SHIP, for students and dependents). 

Benefits

We invite you to visit Harvard's Total Rewards website (https://hr.harvard.edu/totalrewards) to learn more about our outstanding benefits package, which may include:

• Paid Time Off: 3-4 weeks of accrued vacation time per year (3 weeks for support staff and 4 weeks for administrative/professional staff), 12 accrued sick days per year, 12.5 holidays plus a Winter Recess in December/January, 3 personal days per year (prorated based on date of hire), and up to 12 weeks of paid leave for new parents who are primary care givers.
• Health and Welfare: Comprehensive medical, dental, and vision benefits, disability and life insurance programs, along with voluntary benefits. Most coverage begins as of your start date.
• Work/Life and Wellness: Child and elder/adult care resources including on campus childcare centers, Employee Assistance Program, and wellness programs related to stress management, nutrition, meditation, and more.
• Retirement: University-funded retirement plan with contributions from 5% to 15% of eligible compensation, based on age and earnings with full vesting after 3 years of service.
• Tuition Assistance Program: Competitive program including $40 per class at the Harvard Extension School and reduced tuition through other participating Harvard graduate schools.
• Tuition Reimbursement: Program that provides 75% to 90% reimbursement up to $5,250 per calendar year for eligible courses taken at other accredited institutions.
• Professional Development: Programs and classes at little or no cost, including through the Harvard Center for Workplace Development and LinkedIn Learning.
• Commuting and Transportation: Various commuter options handled through the Parking Office, including discounted parking, half-priced public transportation passes and pre-tax transit passes, biking benefits, and more.
• Harvard Facilities Access, Discounts and Perks: Access to Harvard athletic and fitness facilities, libraries, campus events, credit union, and more, as well as discounts to various types of services (legal, financial, etc.) and cultural and leisure activities throughout metro-Boston.

Job Function

Health Care

Department Office Location

USA - MA - Cambridge

Job Code

W0157P HLT Social Worker III

Work Format

On-Site

Sub-Unit

------------

Salary Grade

057

Department

Care Coordination

Union

00 - Non Union, Exempt or Temporary

Time Status

Part-time

Pre-Employment Screening

Criminal, Education, Identity

Schedule

Schedule: To be determined with the hiring manager.

Commitment to Equity, Diversity, Inclusion, and Belonging

Harvard University Health Services is committed to fostering a diverse, inclusive, and equitable workplace in which all employees feel valued and have a sense of belonging. These principles are integral to our work and are at the core of who we are. We actively seek applicants with demonstrated commitment and/or experience promoting and fostering a working and learning environment that is supportive of individuals from diverse backgrounds. We welcome, respect, and embrace individuals from varied backgrounds, cultures, races, identities, life experiences, perspectives, abilities, beliefs, and values. 

EEO Statement

We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, gender identity, sexual orientation, pregnancy and pregnancy-related conditions, or any other characteristic protected by law.