Site: Mass General Brigham Community Physicians, Inc.
Job Summary
The Licensed Clinical Social Worker (LICSW) is a key clinical member of the High-Risk, High-Cost Complex Care Management Program, operating at the top of their license as part of a highly collaborative interdisciplinary team.
• This program is dedicated to preventing unnecessary emergency department (ED) visits and hospitalizations by delivering proactive, patient-centered care that improves health outcomes, reduces healthcare costs, and supports patients in achieving their personal health goals.
• The Social Worker brings expertise in behavioral health, crisis intervention, social determinants of health (SDOH), and patient advocacy within an interdisciplinary care team consisting of:
o Registered Nurses (RNs): Medical care management, disease education, and transitions of care.
o Pharmacists: Medication reconciliation, polypharmacy management, and adherence support.
o Non-Clinical Care Coordinators: Administrative support, appointment scheduling, and resource coordination.
o Community Health Worker.
o Operational Improvement Associate: Data analysis, documentation oversight, quality improvement, and tracking of key performance indicators (KPIs).
• The Social Worker plays a leadership role in behavioral health integration, social determinant of health barriers, and crisis intervention, ensuring that the care team keeps patients stable in the community and prevents avoidable ED visits and inpatient admissions.
• This role will conduct patient visits and check-ins utilizing all modes of intervention: face-to-face, video, telephone, home/community visits, and Patient Gateway.
• This role will require regular travel to practice sites, emergency departments, hospitals, and patient homes as needed based on the care for the patient.
Primary Responsibilities:
1. Conducts comprehensive behavioral health assessments. Conducts in-depth behavioral health evaluations using validated tools such as PHQ-9, GAD-7, CAGE, and ACEs to identify mental health concerns, and develops behavioral health care plans integrated with medical and social interventions.
2. When appropriate, provides brief, evidence-based therapeutic interventions, including Motivational Interviewing (MI), Cognitive Behavioral Therapy (CBT)-informed techniques, and Solution-Focused Therapy. Also offers psychoeducation on stress management, coping strategies, and behavioral activation to help patients manage anxiety, depression, or trauma.
3. Provides substance use disorder support and harm reduction, including comprehensive SDOH assessments and interventions. Conducts comprehensive screenings to identify social barriers impacting health, including housing instability, food insecurity, transportation issues, and financial stressors.
4. Works to reduce unnecessary behavioral health emergency department visits and behavioral health hospital admissions by identifying high-risk patients using real-time ED visit alerts, hospital discharge data, and predictive analytics to provide early intervention. Conducts outreach to patients with a history of frequent ED visits or inpatient stays, ensuring they have access to primary care, behavioral health support, and community resources.
5. Focuses on crisis prevention and de-escalation by providing early intervention for patients with escalating behavioral health or social crises, ensuring appropriate community-based support is in place, offering same-day or next-day behavioral health support for patients experiencing acute distress, avoiding the need for ED visits, and working with community behavioral health agencies and law enforcement alternatives to divert patients from unnecessary ED use.
6. Collaborates with primary care providers (PCPs), behavioral health specialists, urgent care clinics, and community mental health programs to ensure patients access lower-acuity care settings instead of the ED. Also works with pharmacists to resolve medication-related ED visits, such as withdrawal symptoms, medication side effects, or adherence challenges.
7. Provides post-hospitalization support by conducting post-discharge outreach within 24–48 hours to assess social, behavioral, and logistical barriers to recovery, identify patients at high risk for readmission, and ensure they have intensive post-hospital support.
8. Works with each member of the care team to serve as the behavioral health and SDOH expert, ensuring medical, behavioral, and social care are seamlessly integrated.
9. Provides patient education on substance use disorder and mental health concerns and assists clinical teams in evaluating a patient’s need for behavioral health services.
10. Able and willing to travel and meet with patients at practice locations, hospitals, emergency departments, and patient homes within a defined region of care. This is a hybrid role requiring travel and onsite work at least four days a week.
11. Other duties as assigned.
Qualifications
Required:
Preferred:
Master’s Degree in Social Work from an accredited institution
Expertise in trauma-informed care, crisis intervention, and SDOH navigation.
Familiarity with HEDIS measures, NCQA case management documentation, and Medicaid/Medicare care models.
Experience with an EHR (Epic preferred)
Additional Job Details (if applicable)
Schedule and Work Model
Full-time, Monday through Friday, standard business hours.
Hybrid work model: In the community (ER, patient homes) and/or on-site at Staniford Street and/or Cambridge Street in Boston, MA up to 4 times per week; remote work on other days.
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
Hybrid
Work Location
50 Staniford Street
Scheduled Weekly Hours
40
Employee Type
Regular
Work Shift
Day (United States of America)
Pay Range
$67,537.60 - $98,238.40/Annual
Grade
7
At 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, premiums 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.
Mass General Brigham Competency Framework
At 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.
