Medical Social Worker

CVS Health•Waterbury, CT

9d•$51,256 - $111,351

About The Position

The Medical Social Worker is a key member of Oak Street Health Centers, contributing a unique perspective to care teams to support patients’ psychosocial needs. In collaboration with the interdisciplinary care team, the Medical Social Worker provides assessments, advocacy, and comprehensive care coordination to high-risk patients and their caregivers, helping improve health status and avoid hospitalizations. The role supports high-need patients through assessments, telephonic check-ins, and in-person visits; works with patients and support persons to set goals, increase healthcare engagement, address barriers, and implement care plans; and connects patients with community resources. The Medical Social Worker also helps patients navigate insurance benefits, coordinates care longitudinally and episodically, and educates patients about supportive care options, advance care planning, end-of-life care, and condition-specific concerns. The position collaborates with care teams and Community Health Workers, provides clinical guidance and consultation, 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 accredited by the Council on Social Work Education (CSWE).
At least a minimal level of licensure in the state where the Oak Street Health Center is located.
Fluency in Spanish, Polish, Russian, or other languages spoken in the communities served, where necessary.
Proficient computer skills, including Microsoft, GSuite, and electronic medical records.
US work authorization.
Motivated, experienced social worker with a problem-solving orientation and a flexible, positive attitude.
Passion for working with Medicare-eligible populations, including older adults, adults with disabilities, and adults with severe and persistent mental illness.

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.

Responsibilities

Provide comprehensive assessments, telephonic check-ins, and in-person visits for highest-need patients.
Partner with patients and, when appropriate, their support persons to identify goals, increase healthcare engagement, address barriers, and execute care plans.
Maintain knowledge of community resources and make referrals to address patients’ healthcare and psychosocial needs.
Navigate patient insurance benefits with the Patient Relations Manager to support mindful use 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 on 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, comprehensive, and timely documentation so care team members can track MSW 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.