Medical Social Worker

CVS Health•Waterbury, CT

About The Position

The Medical Social Worker is a key member of Oak Street Health Centers, contributing a social work perspective to care teams and supporting patients’ psychosocial needs. In collaboration with the interdisciplinary care team, the role provides assessments, advocacy, and comprehensive care coordination to high-risk patients and their caregivers to help improve health status and avoid hospitalizations. The Medical Social Worker supports patients through assessments, telephonic check-ins, and in-person visits; identifies goals and barriers with patients and support persons; connects patients with community resources; and helps patients navigate insurance benefits. The position provides longitudinal and episodic care coordination, supportive-care education and goals-of-care counseling, and psychoeducation for patients and families. It also 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.
Problem-solving orientation, flexibility, and a positive attitude.
Motivation to improve the lives of the individuals Oak Street Health serves.
Passion for working with Medicare-eligible populations, including older adults, adults with disabilities, and adults with severe and persistent mental illness.

Responsibilities

Provide comprehensive assessments, telephonic check-ins, and in-person visits to highest-need patients.
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 in collaboration with the Patient Relations Manager to support mindful utilization and maximization of plan benefits.
Provide longitudinal and episodic comprehensive care coordination to empower patients to manage health conditions independently 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 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.