Medical Social Worker - LCSW
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About The Position
The Medical Social Worker is a key member of Oak Street Health Centers, contributing a unique and valuable perspective to care teams to support the psychosocial needs of our patients. In collaboration with the interdisciplinary care team, they will provide assessments, advocacy, and comprehensive care coordination services to our highest-risk patients and their caregivers to help them improve their health status and avoid hospitalizations. This role is essential in ensuring that patients receive the support they need to navigate their healthcare journey effectively. The Medical Social Worker will proactively support our highest-need patients by providing comprehensive assessments, telephonic check-ins, and in-person visits. They will partner with the patient and their support persons (if necessary) to identify goals, increase engagement in their healthcare, address barriers, and drive the execution of their care plan. Maintaining extensive knowledge of community resources is crucial, as the Medical Social Worker will make referrals to help ensure that the patient's healthcare and psychosocial needs are met. In addition, the Medical Social Worker will navigate patient insurance benefits in collaboration with the Patient Relations Manager (PRM) to ensure mindful utilization and maximization of plan benefits. They will provide both longitudinal and episodic comprehensive care coordination with the ultimate goal of empowering patients to independently manage their health conditions and improve their quality of life. Education on supportive care options, including advance care planning and end-of-life care, will also be a significant part of this role, along with providing goals of care counseling, support, and advocacy at all stages of the patient journey. The Medical Social Worker will also provide psychoeducation to patients and families surrounding life stage and disease-specific issues, including dementia, adjustment to illness, aging, and caregiver support. They will meet with care teams to collaborate and generate creative solutions to patient issues, spearheading interventions in situations with complex psychosocial dynamics. Timely and concise documentation is essential to ensure that all care team members have visibility into the status of MSW interventions. Additionally, the Medical Social Worker will partner with Community Health Workers, providing clinical guidance and consultation regarding complex patient needs. Responding to crises and urgent needs with the ability to prioritize work, triage situations, and multitask is also a critical aspect of this role.
