Geriatric Social Worker II - Home-Based Care Coordination

Mass General Brigham Community Physicians, Inc.; Somerville (MA); Hybrid; USD 84,000 - 113,000; Full time

Job summary

Mass General Brigham Community Physicians, Inc. is seeking a GRACE Social Worker to provide in-home geriatric assessments and expert care management for high‑risk older adults.

The role emphasizes collaborative planning with PCPs and a multidisciplinary GRACE team to optimize outcomes and respect patient goals. The position is full-time, hybrid, with 36 hours of clinical work and 4 hours of administrative time weekly, primarily in the Boston area, including home visits and remote days as needed.

Qualifications

• MSW degree and licensure preferred.
• Experience in geriatric or home-based care.
• Strong assessment and care planning skills.

Responsibilities

• Screening and in-home psychosocial assessment of older adults.
• Develop and implement individualized care plans using GRACE protocols.
• Coordinate care with primary care providers and interdisciplinary team.
• Provide education on community resources, benefits, and advance directives.
• Advocate for patient autonomy and connect families with needed services.

Skills

Geriatrics

Home visits

Care coordination

Psychosocial support

Education

MSW

Tools

EMR

Job description

Mass General Brigham Community Physicians, Inc. is seeking a GRACE Social Worker to provide in-home geriatric assessments and expert care management for high‑risk older adults.

The role emphasizes collaborative planning with PCPs and a multidisciplinary GRACE team to optimize outcomes and respect patient goals. The position is full-time, hybrid, with 36 hours of clinical work and 4 hours of administrative time weekly, primarily in the Boston area, including home visits and remote days as needed.