Medical Social Worker
About The Position
The Medical Social Worker is a key member of Oak Street Health Centers, bringing a psychosocial perspective to care teams and supporting the needs of patients. Working with the interdisciplinary care team, the Medical Social Worker provides assessments, advocacy, and comprehensive care coordination for high-risk patients and their caregivers to help improve health status and avoid hospitalizations. The role includes supporting patients through in-person visits and telephonic check-ins, connecting them with community resources and insurance benefits, providing education and counseling, and coordinating care to empower patients to manage their health and improve quality of life. The position 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 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.
- U.S. work authorization.
- Motivated, experienced social worker with a problem-solving orientation and a flexible, positive attitude.
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.
- Passion for working with Medicare-eligible populations, including older adults, adults with disabilities, and adults with severe and persistent mental illness.
Responsibilities
- Support high-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 carry out care plans.
- Maintain knowledge of community resources and make referrals to address patients' healthcare and psychosocial needs.
- Navigate patient insurance benefits in collaboration 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 health conditions independently and improve quality of life.
- Educate patients on supportive care options, including advance care planning and end-of-life care, and provide goals-of-care counseling, support, and advocacy throughout the patient journey.
- Provide psychoeducation to patients and families on life-stage and disease-specific topics, 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 social work 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.
Benefits
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- CVS Health bonus, commission, or short-term incentive program eligibility
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What This Job Offers
Job Type
Full-time
