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The Medical Social Worker is a key member of Oak Street Health Centers, contributing a unique and valuable perspective to care teams to support the psychosocial needs of our patients. In collaboration with the interdisciplinary care team, they will provide assessments, advocacy, and comprehensive care coordination services to our highest-risk patients and their caregivers to help them improve their health status and avoid hospitalizations.
Job Responsibility:
Proactively support our highest-need patients by providing comprehensive assessments, telephonic check-ins, and in-person visits
partner with the patient and their support persons (if necessary) to identify goals, increase engagement in their healthcare, address barriers, and drive the execution of their care plan
maintain extensive knowledge of community resources and make referrals, as appropriate, to help ensure the patient's healthcare and psychosocial needs are met
navigate patient insurance benefits in collaboration with the Patient Relations Manager (PRM) to ensure mindful utilization and maximization of plan benefits
provide both longitudinal and episodic comprehensive care coordination with the ultimate goal of empowering patients to independently manage their health conditions and have increased 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 at all stages of the patient journey
provide psychoeducation to patients and families surrounding life stage and disease-specific issues, including dementia, adjustment to illness, aging, caregiver support, etc.
meet with care teams to collaborate and generate creative solutions to patient issues, and spearhead intervention in situations with complex psychosocial dynamics
complete concise and comprehensive documentation on time to ensure that all care team members have visibility into the status of MSW interventions
partner with Community Health Workers and provide clinical guidance and consultation regarding complex patient needs to these team members
respond to crises and urgent needs with the keen ability to prioritize work, triage situations, and multitask
other duties as assigned
Requirements:
Master of Social Work degree required from a school of social work accredited by the Council on Social Work Education (CSWE)
minimally licensed in the state where OSH Center is located
fluency in Spanish, Polish, Russian, or other languages spoken by people in the communities we serve
proficient computer skills (including Microsoft, GSuite, and electronic medical records)
US work authorization
Nice to have:
Prior experience with complex care coordination and/or population healthcare management
familiarity with using metrics and data to guide practice and drive outcomes
minimum one year of medical social work experience in a healthcare environment, preferably within the last two years
experience working on a multidisciplinary team of other healthcare providers
What we offer:
Affordable medical plan options
401(k) plan (including matching company contributions)
employee stock purchase plan
no-cost programs including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
benefit solutions including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access
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