Medical Social Worker

CVS Health•Cypress, TX

About The Position

The Medical Social Worker is a key member of Oak Street Health Centers, bringing a distinct perspective to care teams as they address patients’ psychosocial needs. In collaboration with the interdisciplinary care team, the role provides assessments, advocacy, and comprehensive care coordination for high-risk patients and their caregivers, with the goal of improving health status and helping patients avoid hospitalizations. The Medical Social Worker supports patients through assessments, telephonic check-ins, and in-person visits; works with patients and support persons to identify goals, improve healthcare engagement, address barriers, and carry out care plans; and connects patients with appropriate community resources. The role also helps patients navigate insurance benefits, coordinates care longitudinally and episodically, provides education and counseling about supportive care and end-of-life options, and offers psychoeducation to patients and families on life-stage and disease-specific issues. The position collaborates with care teams to develop solutions for complex psychosocial situations, documents interventions, offers clinical guidance to Community Health Workers, and responds to urgent needs and crises. The 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 minimally licensed in the state where the Oak Street Health Center is located.
Fluency in Spanish, Polish, Russian, or another language spoken by people 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, driven to improve the lives of the individuals served.
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 high-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 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 their health conditions 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 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 involving complex psychosocial dynamics.
Complete concise and 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.