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Fallon Health Licensed Social Worker - ACO Team - (Work Remote + 1 day/week in Medical Practice ) in Lowell, Massachusetts


About Fallon Health:

Fallon Health is a mission-driven not-for-profit health care services organization based in Worcester, Massachusetts. For 45 years we have been improving health and inspiring hope in the communities we serve. Committed to caring for those who need us most, we pride ourselves on providing equitable access to coordinated, integrated care for our members with a special focus on those who qualify for Medicare and Medicaid. We also serve as a provider of care through our Program of All-Inclusive Care for the Elderly (PACE). Dedicated to delivering high quality health care, we are continually rated among the nation’s top health plans for member experience and service and clinical quality.

Brief Summary of Purpose:

The Social Work Care Manager (SWCM) works very closely with ACO and other product Partners, Community Partners, and/ or community based groups to address service gaps and serves as a liaison to social and health resources on behalf of Fallon Health and the Fallon Health Care Management Models of Care.

The SWCM collaborates and coordinates with State Agencies, DMH, DDS, DYS, DCF to ensure members care is efficient and coordinated.

The SWCM provides social service coordination services to members as referred assessing member needs, services and resources to address social, health, or economic needs and facilitates referrals and collaboration with Provider Care Teams and BH Partners in the community.

The SWCM assists the member and or family to provide care utilizing FH benefits and/or community resources developing a plan to coordinate a continuum of care consistent with the members’ health care needs and/or goals. The SWCM uses their knowledge of benefit plan design, eligibility and/or financing alternatives available within the community to provide options that meet member’s needs.

The SWCM identifies services, care delivery settings, and funding arrangements that meet the needs of the members. He/She recommends alternatives where appropriate. The SWCM monitors services and provides consistent feedback to the team on progress.

The SWCM collaborates and works with members of the Care Team both at Fallon Health and at the Community Partners during time of member transition of care.

May attend in person care planning meetings, care coordination meetings, partner communication meetings, and other face-to-face meetings with providers, partners, and members to perform assessments, train staff, coordination communication and otherwise represent Fallon Health in a positive way.


Job Responsibilities:

Member Care Coordination and Collaboration

  • Provides culturally appropriate care coordination, i.e. works with interpreters, provides communication approved documents in the appropriate language, and demonstrates culturally appropriate behavior when working with member, family, caregivers, and/or authorized representatives

  • With member/authorized representative(s) collaboration develops member centered care plans by identifying member care needs while completing program assessments and working with the Care Coordinator to ensure the member approves their care plan

  • Monitors progression of member goals and care plan goals, provides feedback and works collaboratively with care team members and work effectively in a team model approach to coordinate a continuum of care consistent with the Member’s health care goals and needs

  • Actively participates in internal clinical rounds and huddles

  • Works with members of the Utilization Management Department assisting with difficult or complex care delivery or discharge planning needs for members

  • Actively participate with Beacon team and collaborate on high risk members to decrease utilization

  • May collaborate with staff on site to facilitate communication between Fallon and community based teams

  • Assists with care coordination with community Partners to engage in Interdisciplinary team meetings

  • Works with Nurse Case Managers and Navigators to coordinate a continuum of care for members consistent with the member’s health care goals and needs

  • Maintains an ongoing awareness of clinical, social, and financial resources available in the community as well as State/Federal and National Resources and connects and advocates for members as appropriate

  • Performs other responsibilities as assigned by a member of the Clinical Integration Leadership Team

  • Participates in monthly supervision and one on one meetings with the manager



Master’s degree from an accredited school of social work, mental health counseling, psychology, or human services required.


  • Active, unrestricted license as a Licensed Clinical Social Worker or Counselor in Massachusetts; reliable transportation

  • Certification in Case Management strongly desired


Satisfactory Criminal Offender Record Information (CORI) results.


  • Four years of experience working with the following: the chronically ill, SPMI, and substance use populations required.

  • Experience and comfort conducting face-to-face visits with members in the community and in home settings required.

  • Experience working in a multi-disciplinary care team required.

  • Experience working and providing collaborative care management interventions with various State Agencies such as DMH, DDS, DCF, DYS required.

  • Experience working with provider groups such as medical and/or mental health providers required.

  • Background working with all age groups preferred.

  • Previous experience working at a Managed Care Organization preferred.

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

Fallon Health Vaccination Requirements:

To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022 all roles not designated as “Remote” require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

Location US-MA-Lowell

Posted Date 2 months ago (1/18/2023 3:14 PM)

Job ID 7170

# Positions 1

Category Social Work