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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. The role involves assessments, advocacy, and comprehensive care coordination for high-risk patients to help them improve their health and avoid hospitalizations. Responsibilities include patient support, community resource navigation, education, coordination, and collaboration with other health providers.
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
Navigate patient insurance benefits in collaboration with the Patient Relations Manager (PRM)
Provide both longitudinal and episodic comprehensive care coordination to empower patients
Educate patients on supportive care options including advance care planning and end-of-life care
Provide psychoeducation to patients and families surrounding life stage and disease-specific issues
Meet with care teams to collaborate and generate creative solutions
Complete concise and comprehensive documentation on time
Partner with Community Health Workers and provide clinical guidance
Respond to crises and urgent needs with the ability to prioritize work, triage situations, and multitask
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
What we offer:
Affordable medical plan options
401(k) plan including matching company contributions
Employee stock purchase plan
No-cost wellness screenings, tobacco cessation and weight management programs
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