Medical Social Worker

CVS Health•Aurora, CO

9d•$51,256 - $111,351

About The Position

The Medical Social Worker is a key member of Oak Street Health Centers and contributes a psychosocial perspective to interdisciplinary care teams. The role supports the psychosocial needs of patients, particularly those at highest risk, and their caregivers through assessments, advocacy, and comprehensive care coordination intended to improve health status and help prevent hospitalizations. The Medical Social Worker provides longitudinal and episodic care coordination, works with patients and support persons to identify goals and address barriers, connects patients with community resources, and helps them navigate insurance benefits. The position also includes education and counseling on supportive care options, advance care planning, end-of-life care, and life-stage or disease-specific concerns. The Medical Social Worker collaborates with care teams and Community Health Workers, documents interventions, and responds to crises and urgent needs. This role reports to the Practice Manager.

Requirements

Master of Social Work degree from a school of social work accredited by the Council on Social Work Education (CSWE).
At least minimally licensed in the state where the Oak Street Health Center is located.
Fluency in Spanish, Polish, Russian, or another language spoken in the communities served, where necessary.
Proficient computer skills, including Microsoft, GSuite, and electronic medical records.
US work authorization.

Nice To Haves

Prior experience with complex care coordination and/or population healthcare management.
Familiarity with using metrics and data to guide practice and drive outcomes.
At least one year of medical social work experience in a healthcare environment, preferably within the last two years.
Experience working on a multidisciplinary team of healthcare providers.
A problem-solving orientation and a flexible, positive attitude, with motivation to improve the lives of the individuals served by Oak Street Health.
Passion for working with Medicare-eligible populations, including older adults, adults with disabilities, and adults with severe and persistent mental illness.

Responsibilities

Support highest-need patients through comprehensive assessments, telephonic check-ins, and in-person visits.
Work with patients and their support persons to identify goals, increase healthcare engagement, address barriers, and carry out care plans.
Maintain knowledge of community resources and make appropriate referrals to help meet patients' healthcare and psychosocial needs.
Collaborate with the Patient Relations Manager to navigate insurance benefits and support mindful utilization and maximization of plan benefits.
Provide longitudinal and episodic comprehensive care coordination to empower patients to manage health conditions and improve quality of life.
Educate patients about supportive care options, including advance care planning and end-of-life care, and provide goals-of-care counseling, support, and advocacy.
Provide psychoeducation to patients and families about life-stage and disease-specific issues, including dementia, adjustment to illness, aging, and caregiver support.
Collaborate with care teams to develop solutions to patient issues and lead interventions involving complex psychosocial dynamics.
Complete concise and comprehensive documentation on time so care team members can see the status of interventions.
Partner with Community Health Workers and provide clinical guidance and consultation on complex patient needs.
Respond to crises and urgent needs by prioritizing work, triaging situations, and multitasking.
Perform other duties as assigned.