Geriatric Social Worker / Case Manager – Older Adult Care | Full-Time (Part-Time may be considered)

The Staff Pad is proud to partner with a leading healthcare organization in Lawrence, MA, to recruit a compassionate and experienced Geriatric Social Worker / Case Manager. In this role, you’ll help older adults navigate the medical, emotional, behavioral health, and social challenges that impact their well-being, independence, and quality of life. Working closely with physicians, nurse practitioners, nurses, patients, families, and community partners, you’ll coordinate personalized care, connect patients with essential resources, and build meaningful relationships that make a lasting difference. Schedule: Full-Time | Part-Time Considered Work Environment: Community-Based Primary Care | Office, Home Visits, and Senior Living Communities What You’ll Do Key Responsibilities Geriatric Psychosocial Assessment & Care Planning Assess older adults’ living situations, cognitive and emotional health, caregiver support, finances, and social needs Identify risks related to social isolation, mental health concerns, elder abuse, self-neglect, caregiver burnout, and loss of independence Develop personalized care plans with patients, families, and the primary care team Guide patients and families through dementia, declining function, and changing care needs Care Coordination & Community Resource Management Connect patients with home care, transportation, meal programs, housing, elder services, and financial assistance Partner with Massachusetts Aging Services Access Points (ASAPs), elder service organizations, home health agencies, hospitals, rehabilitation facilities, and community programs Coordinate transitions from hospitals and skilled nursing facilities to home or senior living communities Help patients navigate Medicare, Medicaid/MassHealth, and other benefit programs Address social barriers contributing to avoidable emergency department visits, hospitalizations, and poor health outcomes Behavioral Health & Cognitive Support Screen for depression, anxiety, substance use, caregiver distress, and other behavioral health concerns Provide supportive counseling, brief interventions, and appropriate mental health referrals within professional scope Support patients with Alzheimer’s disease and other dementias while educating and counseling family caregivers Assist with advance care planning, healthcare proxy documentation, goals-of-care discussions, and appropriate palliative or hospice referrals Collaborate with the primary care team to address complex medical, behavioral, and social needs Value-Based Care & Population Health Identify and proactively engage high-risk and medically complex patients Partner with clinicians and care managers to reduce avoidable emergency department visits and hospitalizations Address care gaps related to social needs, behavioral health, and access to medical services Document assessments, interventions, referrals, and follow-ups in Athenahealth Participate in interdisciplinary case conferences and quality improvement initiatives Help develop innovative care management programs for older adults Patient & Family Advocacy Build trusted, lasting relationships with patients, caregivers, and families Guide families through the emotional, practical, and financial challenges of caring for aging loved ones Facilitate communication among patients, families, healthcare providers, and community organizations Advocate for patient preferences, dignity, independence, and quality of life What We’re Looking For Required Education, Experience & Licensure Bachelor’s or master’s degree in Social Work or a related field from an accredited institution Active Massachusetts LSW, LCSW, or LICSW license in good standing Experience supporting older adults, medically complex patients, or vulnerable populations Preferred Experience & Knowledge 3+ years of experience in geriatrics, primary care, hospital discharge planning, home health, hospice, or community-based care management Experience supporting patients with dementia and their caregivers Experience in an Accountable Care Organization (ACO), population health, or value-based care setting Experience with Athenahealth or a similar electronic medical record Knowledge of Massachusetts elder services, MassHealth, Medicare, and community resources Familiarity with motivational interviewing, brief behavioral health interventions, and interdisciplinary care planning Additional Skills & Requirements Strong clinical assessment, communication, organizational, and problem-solving skills Ability to work independently and collaboratively within an interdisciplinary healthcare team Comfort with community-based visits and communicating with patients and caregivers by phone or video Valid driver’s license and reliable transportation for patient visits What You Can Expect Competitive compensation Comprehensive benefits Life and disability insurance Flexible Spending Account (FSA) Employee Assistance Program (EAP) Paid time off and sick time Holiday pay 401(k) retirement plan If you’re a compassionate and proactive professional passionate about advocating for older adults, building meaningful patient relationships, and improving health outcomes, this is an excellent opportunity to grow your career while working independently and collaborating with a supportive, multidisciplinary team dedicated to patient-centered care. Apply today!