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Title: Medical Social Worker
Company: Oak Street Health

REQUIRED QUALIFICATIONS:

• 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

STRONGLY PREFERRED QUALIFICATIONS:

• 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

PREFERRED QUALIFICATIONS:

• Experience working on a multidisciplinary team of other healthcare providers

OTHER SKILLS

• Motivated, experienced social workers with a problem-solving orientation and a flexible and positive attitude who are driven to improve the lives of the individuals that OSH serves.
• Passion for working with Medicare-eligible populations, including older adults, adults with disabilities, and adults with severe and persistent mental illness

ROLE DESCRIPTION:

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.

CORE RESPONSIBILITIES:

• 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.
  This role reports to the Practice Manager.