Medical Social Worker

CVS Health•Marietta, GA

About The Position

The Medical Social Worker is a member of Oak Street Health Centers’ care teams and contributes a psychosocial perspective to support patients’ needs. Working with the interdisciplinary care team, the role provides assessment, advocacy, and comprehensive care coordination for high-risk patients and their caregivers, with the goals of improving health status and helping avoid hospitalizations. The Medical Social Worker supports patients through assessments, telephonic check-ins, and in-person visits; partners with patients and support persons to identify goals and address barriers; connects patients with community resources; and coordinates care longitudinally and episodically. The role also provides education and counseling on supportive care, advance care planning, end-of-life care, and life-stage or disease-specific issues. The position collaborates with care teams and Community Health Workers, documents interventions, and responds to crises and urgent needs. The role reports to the Practice Manager.

Requirements

Master of Social Work degree from a Council on Social Work Education-accredited school of social work.
At least a state-minimum social work license in the state where the Oak Street Health Center is located (LCSW/LSW).
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.
Experience conducting patient or client home visits.
Two years of experience as a Medical Social Worker.
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.
Three years 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

Proactively support highest-need patients through comprehensive assessments, telephonic check-ins, and in-person visits.
Partner with patients and, when necessary, their support persons to identify goals, increase healthcare engagement, address barriers, and execute care plans.
Maintain knowledge of community resources and make referrals to help meet patients’ healthcare and psychosocial needs.
Navigate patient insurance benefits with the Patient Relations Manager to support mindful utilization and maximize plan benefits.
Provide longitudinal and episodic comprehensive care coordination to empower patients to manage their 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 in situations involving complex psychosocial dynamics.
Complete concise, 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 regarding complex patient needs.
Respond to crises and urgent needs by prioritizing work, triaging situations, and multitasking.
Perform other duties as assigned.