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Requisition Number:

R-22320

Facility:

LOC0020 - 143 Longwater Norwell143 Longwater DriveNorwell, MA 02061

Department Name:

SSH Population Health

Status:

Full time

Budgeted Hours:

40

Shift:

Day (United States of America)

Under the direction of the Ambulatory Case Management Officer (ACMO), the Manager of Ambulatory Case Management & Social Work provides operational leadership and strategic direction for South Shore Health's ambulatory case management and social work functions. This role oversees day-to-day operations, resource allocation, and team prioritization across five core areas: CMS TEAM episodic bundle coordination and preferred SNF network management; ambulatory case management and social work support for SSMC and other SSH practices; Workers' Compensation case management oversight; relationship management with delegated case management organizations under VBC and risk contracts; and general day-to-day team supervision, mentoring, and performance management. The Manager supervises seven to eight direct and dotted-line reports and promotes individualized, goal-directed case management aligned with departmental and health system policies.

Compensation Pay Range:

$145,000.00 - $210,300.00

ESSENTIAL FUNCTIONS

1- Oversees CMS TEAM Program case management and preferred SNF network performance.

a- Provides operational oversight of case management activities supporting the CMS TEAM episodic bundle program, including pre-operative outreach, post-discharge follow-up, and ED return monitoring for LEJR and hip fracture surgical episodes.

b- Manages preferred SNF partner relationships, including coordination of embedded CM specialist rounding, SNF pathway compliance monitoring, and performance tracking against length-of-stay targets and SNF-to-ED transfer rates.

c- Partners with the ACMO and surgical service line leaders to identify TEAM bundle performance gaps and develop proactive case management interventions.

d- Monitors SNF-associated quality indicators including HAI prevention, Foley catheter protocols, antibiotic stewardship, and C-diff detection to reduce downstream impacts on VBP, Leapfrog, and CMS star ratings.

2- Provides case management and social work oversight for SSMC and SSH ambulatory practices.

a- Oversees case management and social work services across SSMC and other SSH ambulatory practices, ensuring proactive identification and management of high-risk patients including complex chronic care, SDOH needs, and care transitions.

b- Rounds regularly with ambulatory nursing and practice leadership to assess case management and social work needs, coordinate team resources, and address emerging care gaps.

c- Ensures appropriate and timely utilization of community resources including VNA, DME, Meals on Wheels, and behavioral health services for ambulatory patients requiring transitional or ongoing support.

d- Oversees primary and specialty care referral processes to ensure timely access and continuity of care for managed populations.

3- Provides guidance and oversight for Workers' Compensation case management.

a- Provides dotted-line supervisory guidance to Workers' Compensation RN case managers in Employee Health, ensuring consistent application of case management principles and SSH policies.

b- Serves as a clinical resource for complex Workers' Compensation cases, facilitating coordination among Employee Health, treating providers, and third-party payers.

c- Monitors Workers' Compensation case management practices against regulatory requirements and occupational health best practices, escalating concerns to the ACMO as appropriate.

4- Manages relationships with delegated and third-party case management organizations under VBC and risk contracts.

a- Under the direction of the ACMO, maintains collaborative working relationships with delegated case management organizations supporting SSH's Medicare ACO population and other value-based care contracts.

b- Monitors performance accountability of external case management partners, ensuring alignment with SSH quality, utilization, and care coordination goals.

c- Serves as operational liaison between SSH ambulatory case management and external organizations, facilitating communication and care handoffs for shared patients.

d- Maintains working knowledge of VBC contract structures, Medicare ACO population health requirements, and third-party payer case management programs relevant to SSH's risk portfolio.

5 - Leads day-to-day team operations, staff supervision, and professional development.

a- Supervises, mentors, and develops all ambulatory case managers and social workers; conducts performance appraisals, sets individual goals, and implements progressive discipline in accordance with HR policies as needed.

b- Manages daily staffing, workload distribution, and scheduling to ensure adequate coverage across all ambulatory case management functions.

c- Orients and trains new staff using SSH orientation and competency frameworks; develops individualized annual educational plans based on staff needs assessments.

d- Facilitates regular team meetings to review case complexity, clinical skill development, productivity, and operational priorities.

e- Maintains chart audit and documentation review processes in support of quality, compliance, and continuous improvement standards.

f- Provides coverage for the ACMO and represents the department at interdisciplinary meetings and organizational committees as needed.

Technology and Learning

a- Participates in continued learning and possesses a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organization.

b- Embraces technological advances that allow us to communicate information effectively and efficiently based on role.

Weekday, days

Responsibilities if Required:

Education if Required:

License/Registration/Certification Requirements:

Accredited Case Manager (ACM) - National Board for Case Management (NBCM) - National Board for Case Management (NBCM), Certified Case Manager (CCM) - Commission for Case Manager Certification (CCMC) - Commission for Case Manager Certification (CCMC), RN-Registered Nurse- Board of Registration in Nursing (Massachusetts)