Manager, Ambulatory Case Management and Social Work

If you are an existing employee of South Shore Health then please apply through the internal career site.

R-22320

Facility:

LOC0020 - 143 Longwater Norwell143 Longwater Drive Norwell, MA 02061

SSH Population Health

Full time

40

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

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)