Complex Care Case Manager - LCSW, LICSW, LMHC
- Conduct comprehensive assessments (telephonic, in-home, or community-based) to identify medical, behavioral, and social needs
- Build rapport using trauma-informed care, motivational interviewing, and harm reduction approaches
- Develop individualized care plans in collaboration with members, caregivers, primary care teams, and community partners
- Document member goals, barriers, and interventions in the EMR and/or case management platform
- Coordinate services across behavioral health, primary care, housing, food access, transportation, and other SDOH
- Provide warm handoffs to internal staff (e.g., CHWs, RNs) and external partners
- Refer and link members to community supports, Community Partners, and Long-Term Services & Supports (LTSS) programs
- Facilitate team-based case reviews and advocate for member needs across the care continuum
- Monitor care plan progress, address gaps in care, and update care plans as needed
- Collaborate with nursing staff and behavioral health clinicians
- Track avoidable ED visits and ensure members have follow-up support after hospital or ED discharge
- Support program evaluation efforts and quality improvement initiatives related to ED utilization
- Participate in regular team huddles, ACO partner meetings, and cross-functional workgroups
- Maintain timely, professional communication with providers, staff, and community agencies
- Participate in program development and provide feedback to enhance workflows
- Knowledge of local community resources, Medicaid ACO programs, and SDOH
- Ability to prioritize, problem-solve, and manage a dynamic caseload
- Experience working with vulnerable populations, including those with SPMI, substance use disorders, or unstable housing
- Strong written and verbal communication skills
- Proficiency with Microsoft Excel and EHR platforms
- Minimum 35 years experience in care coordination, case management, or community health
- Preferred: Experience working with high-utilizer populations, behavioral health, substance use, and social determinants of health (SDOH)
- Masters degree in social work, Mental Health Counseling, or related Human Services field required.
- Active, unrestricted license as LCSW, LICSW, or LMHC in Massachusetts
- Reliable transportation required
- Certification in Case Management preferred
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