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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 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
Navigate patient insurance benefits in collaboration with the Patient Relations Manager
Provide both longitudinal and episodic comprehensive care coordination
Educate patients on supportive care options and provide goals of care counseling
Provide psychoeducation to patients and families surrounding life stage and disease-specific issues
Meet with care teams to collaborate and generate creative solutions to patient issues
Complete concise and comprehensive documentation on time
Partner with Community Health Workers and provide clinical guidance
Respond to crises and urgent needs
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 (where necessary)
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
Motivated, experienced social workers with a problem-solving orientation and a flexible and positive attitude
Passion for working with Medicare-eligible populations, including older adults, adults with disabilities, and adults with severe and persistent mental illness
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