Medical Social Worker-OSH

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 patients. In collaboration with the interdisciplinary care team, they will provide assessments, advocacy, and comprehensive care coordination services to the highest-risk patients and their caregivers to help them improve their health status and avoid hospitalizations. This role reports to the Practice Manager.

Responsibilities

Proactively support highest-need patients by providing comprehensive assessments, telephonic check-ins, and in-person visits; Partner with patients and their support persons to identify goals, increase engagement in healthcare, address barriers, and drive execution of care plans; Maintain knowledge of community resources and make referrals as appropriate; Navigate patient insurance benefits in collaboration with the Patient Relations Manager (PRM); Provide longitudinal and episodic comprehensive care coordination; Educate patients on supportive care options, including advance care planning and end-of-life care, and provide goals of care counseling; Provide psychoeducation to patients and families on life stage and disease-specific issues; Meet with care teams to generate solutions to patient issues and spearhead intervention in complex psychosocial situations; Complete concise and comprehensive documentation on time; Partner with Community Health Workers and provide clinical guidance and consultation; Respond to crises and urgent needs, prioritize work, triage situations, and multitask; Other duties as assigned

Requirements

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 the OSH Center is located; Fluency in Spanish, Polish, Russian, or other languages spoken by people in the communities served (where necessary); Proficient computer skills (including Microsoft, GSuite, and electronic medical records); US work authorization; 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); Passion for working with Medicare-eligible populations, including older adults, adults with disabilities, and adults with severe and persistent mental illness

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; Passion for working with Medicare-eligible populations; Motivated, experienced social workers with a problem-solving orientation and a flexible and positive attitude

Benefits

Medical, dental, and vision coverage; Paid time off; Retirement savings options; Wellness programs; Other resources based on eligibility; Eligibility for CVS Health bonus, commission, or short-term incentive program