Social Work Care Manager, BH TOC

career locationBoston, MA

career datePosted February 6, 2023

career description Download PDF

Program/s: Community Care Cooperative

Reports to: Manager, Behavioral Health Transitions of Care Program

Classification: Individual Contributor

Job description revision number: v3

The Social Worker with the Transitions of Care team (TOC) will have the opportunity to make a profound impact on the lives of people living with complex mental health, behavioral, and substance abuse needs. The Social Worker will serve as a critical member of the integrated care team, which is made up of community health workers, pharmacists, FQHC staff, and program coordinators. They must be prepared to work from home office, hospital, Health Center, provider’s office setting, within patient’s homes, or in the community. 


  • Engages members and caregivers in active care planning to focus on behavioral, social, and environmental concerns and needs 
  • Collaborates with members, caregivers, and inpatient social workers on discharge planning to ensure improved access to care, increase community tenure, and decrease visits to the ED and the risk of psychiatric readmissions 
  • Maintain an on-site presence at assigned hospitals and develop relationships with members’ clinical teams 
  • Assesses the member’s knowledge of their behavioral health conditions and provides education and self-management support based on the member’s preferences 
  • Connects members with primary care, behavioral health, and other services as needed 
  • Establishes relationships with community agencies, resources, and supports that are relevant to the Medicaid population 
  • Meets members while admitted to an inpatient psychiatric unit to provide education about BH TOC support 
  • Completes comprehensive post-discharge assessments and patient-centered care plans 
  • Facilitates medication reconciliation with pharmacist 
  • Travels to engage members at their homes or in the community 
  • Measures, improves, and maintains quality outcomes (clinical, financial, and functional) for individual members and the population served 
  • Maintains accurate and timely documentation in electronic systems 
  • Provides team support as needed 

Required Skills: 

  • Demonstrated success in working as part of a multi-disciplinary team including communicating and working with providers, nurses, and Community Health Workers
  • Skilled in Motivational Interviewing, patient engagement strategies, Risk Assessments, and case management
  • Experience in working with members with mental illness and/or substance misuse disorders 
  • Ability to flexibly utilize clinical expertise to solve complex problems
  • Proven ability to work independently
  • Proven ability to prioritize and flexibly manage a variable workload
  • Excellent interpersonal communication skills and an ability to engage with varying patient populations
  • Experience and proficiency with Microsoft Office suite and online record keeping
  • Excellent organizational and time management skills
  • Skilled at advocating for patients within the medical, psychiatric, and community settings
  • Personal and professional commitment to best-practice patient care   

Desired Other Skills: 

  • Familiarity with the MassHealth ACO program
  • Familiarity with Federally Qualified Health Centers, and/or Health Systems
  • Experience with anti-racism activities, and/or lived experience with racism is highly preferred
  • Bi-lingual (preferred)
  • Medical Assistant, Engagement Specialist, or Community Health Worker Certification
  • Additional qualities that would be a good fit for our team include enthusiasm and passion for helping patients, genuine spirit, kind and empathetic nature  


  • 2-3 years of inpatient or Community Social Work experience providing patient-centered outreach, behavioral health services, needs assessment, and support
  • Master of Social Work or Master in Counseling
  • Current, active MA LCSW, LICSW, or LMHC licensure
  • A valid driver’s license and provision of a working vehicle

Community Care Cooperative (C3) is a 501(c)(3) non-profit, Accountable Care Organization (ACO) governed by Federally Qualified Health Centers (FQHCs). Our mission is to leverage the collective strengths of FQHCs to improve the health and wellness of the people we serve. We are a fast- growing organization founded in 2016 with 9 health centers and now serving hundreds of thousands of beneficiaries who receive primary care at health centers and independent practices across Massachusetts. We are an innovative organization developing new partnerships and programs to improve the health of members and communities, and to strengthen our health center partners.

** In compliance with Covid-19 Infection Control practices per recommendations, we require all employees to be vaccinated consistent with applicable law. * 

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