Medical Social Worker: Care Coordination & Advocacy

Oak Street Health; Richmond (VA); On-site; USD 47,000 - 101,000; Full time

Job summary

Oak Street Health seeks a Medical Social Worker to support psychosocial needs of patients, coordinating care with the interdisciplinary team and guiding patients toward improved health outcomes and reduced hospitalizations.

The role involves assessments, advocacy, and collaboration with care teams, plus navigating insurance benefits and educating patients and families across dementia, aging, and end‑of‑life planning. Full‑time, 40 hours weekly in the US.

Qualifications

• Master of Social Work degree required from a CSWE-accredited program.
• Licensed (minimally) in the state where OSH Center is located.
• Fluency in Spanish, Polish, Russian, or other languages used by local communities.
• Proficient with computers, including Microsoft Office, GSuite, and electronic medical records.
• US work authorization.

Responsibilities

• Provide assessments, advocacy, and care coordination for high‑risk patients and caregivers.
• Perform telephonic check‑ins and in‑person visits for highest‑need patients.
• Collaborate with interdisciplinary care teams to align goals and care plans.
• Navigate insurance benefits with the Patient Relations Manager to maximize benefits.
• Deliver longitudinal and episodic care coordination to empower self‑management.
• Educate on supportive care options and goals of care counseling throughout care journey.
• Provide psychoeducation to patients and families on life stages and diseases.
• Collaborate with care teams to develop creative solutions for psychosocial challenges.
• Document concisely and comprehensively for visibility across the care team.
• Consult with Community Health Workers on complex patient needs.
• Respond to crises and urgent needs with prioritization and multitasking.
• Perform other duties as assigned.

Skills

Multilingual (Spanish/Polish/Russian)

Education

Master of Social Work degree

Tools

Microsoft Office

GSuite

Electronic Medical Records

Job description

Oak Street Health seeks a Medical Social Worker to support psychosocial needs of patients, coordinating care with the interdisciplinary team and guiding patients toward improved health outcomes and reduced hospitalizations.

The role involves assessments, advocacy, and collaboration with care teams, plus navigating insurance benefits and educating patients and families across dementia, aging, and end‑of‑life planning. Full‑time, 40 hours weekly in the US.