Medical Social Worker

CVS Health•Philadelphia, PA

About The Position

The Medical Social Worker (MSW) is a key member of Oak Street Health care teams, contributing a psychosocial perspective to support patients’ needs. The role provides assessments, advocacy, and comprehensive care coordination for high-risk patients and their caregivers, with the goal of improving health status, avoiding hospitalizations, and helping patients live healthier, happier lives. The MSW works with patients, their support persons, and interdisciplinary care teams to address barriers, develop and carry out care plans, respond to urgent needs, connect patients with community resources, and support patients throughout their healthcare journey. The position also provides education, counseling, documentation, and clinical guidance to Community Health Workers.

Requirements

Current Pennsylvania licensure as either a Licensed Clinical Social Worker (LCSW) or Licensed Social Worker (LSW).
Master’s Degree of Social Work (MSW) from an accredited program.
Proficient computer skills, including Microsoft, GSuite, and electronic medical records.
Prior experience with complex care coordination and/or population healthcare management.
US work authorization.

Nice To Haves

Experience using metrics and data to guide practice and drive outcomes.
At least one year of recent medical social work experience in a healthcare environment.
Positive attitude and drive to improve the lives of underserved populations, including older adults, adults with disabilities, and people with chronic mental and physical illnesses.
Ability to adapt, multitask, and remain flexible in a fast-paced environment.
Familiarity with the local community, including socioeconomic challenges, healthcare barriers, and resources to address them.
Experience working on a multidisciplinary team of healthcare providers.
Fluency in another language.

Responsibilities

Support high-need patients through comprehensive assessments, telephonic check-ins, and in-person visits.
Partner with patients and, when appropriate, their support persons to identify goals, increase healthcare engagement, address barriers, and execute care plans.
Respond to crises and urgent needs by prioritizing work, triaging situations, and multitasking.
Maintain knowledge of community resources and make referrals to help meet patients’ healthcare and psychosocial needs.
Navigate patient insurance benefits in collaboration 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 regarding 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 documentation on time so care team members can see the status of MSW interventions.
Partner with Community Health Workers and provide clinical guidance and consultation regarding complex patient needs.
Perform other duties as assigned.