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 include proactively supporting highest-need patients by providing comprehensive assessments, telephonic check-ins, and in-person visits; partnering with patients and their support persons to identify goals, increase engagement in healthcare, address barriers, and drive care plan execution; maintaining extensive knowledge of community resources and making referrals; navigating patient insurance benefits in collaboration with the Patient Relations Manager; providing longitudinal and episodic comprehensive care coordination to empower patients to manage their health conditions and improve quality of life; educating patients on supportive care options including advance care planning and end-of-life care; providing psychoeducation to patients and families on life stage and disease-specific issues; collaborating with care teams to generate solutions and intervene in complex psychosocial situations; completing timely documentation; providing clinical guidance to Community Health Workers; responding to crises and urgent needs; and other duties as assigned. This role reports to the Practice Manager. Required qualifications include a Master of Social Work degree from a CSWE-accredited school, minimal licensure in the state where the OSH Center is located, fluency in Spanish, Polish, Russian, or other community languages as needed, proficient computer skills, and US work authorization. Strongly preferred qualifications include prior experience with complex care coordination or population healthcare management, familiarity with metrics and data to guide practice, and at least one year of recent medical social work experience in healthcare. Preferred qualifications include experience working on multidisciplinary healthcare teams. The role requires motivation, problem-solving orientation, flexibility, and 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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