Medical Social Worker

Role Description

The Medical Social Worker is a key member of Oak Street Health Centers, supporting the psychosocial needs of patients. In collaboration with the interdisciplinary care team, they will provide assessments, advocacy, and comprehensive care coordination services to highest-risk patients and their caregivers to help improve their health status and avoid hospitalizations.

Key Responsibilities

• Proactively support 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 healthcare, address barriers, and drive care plan execution.
• Maintain extensive knowledge of community resources and make referrals to ensure 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 to empower patients to independently manage their health conditions and increase 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.
• 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 for care team visibility.
• Partner with Community Health Workers and provide clinical guidance and consultation regarding complex patient needs.
• Respond to crises and urgent needs with the ability to prioritize work, triage situations, and multitask.
• Other duties as assigned.

Requirements & Tech Stack

• Master of Social Work degree 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.
• Proficient computer skills (including Microsoft, GSuite, and electronic medical records).
• US work authorization.

Qualifications

• Master of Social Work degree.
• State licensure for Medical Social Worker.
• Fluency in Spanish, Polish, Russian, or other languages spoken by communities served (where necessary).
• Prior experience with complex care coordination and/or population healthcare management (Strongly Preferred).
• Familiarity with using metrics and data to guide practice and drive outcomes (Strongly Preferred).
• Minimum one year of medical social work experience in a healthcare environment, preferably within the last two years (Strongly Preferred).
• Experience working on a multidisciplinary team of other healthcare providers (Preferred).
• Motivated, experienced social workers with a problem-solving orientation, a flexible and positive attitude, driven to improve lives.
• Passion for working with Medicare-eligible populations, including older adults, adults with disabilities, and adults with severe and persistent mental illness.