Medical Social Worker: Care Coordination & Advocacy

Preferra Insurance; Warwick (RI); On-site; USD 51,000 - 111,000; Full time

Benefits offered by this job

Medical/Dental/Vision coverage

Paid time off

Retirement savings options

Job summary

Oak Street Health is seeking a Medical Social Worker to join their care teams, providing psychosocial assessments, advocacy, and comprehensive care coordination for high-risk patients and their caregivers. The MSW will collaborate with interdisciplinary teams to improve health outcomes and reduce hospitalizations.

Responsibilities include conducting assessments, coordinating care, navigating resources and benefits, and educating patients on support options, with emphasis on empowerment and

Qualifications

• MSW degree required from a CSWE-accredited school.
• Minimally licensed in the state where OSH Center is located.
• Fluency in Spanish, Polish, Russian, or other languages spoken by communities we serve.
• Proficient computer skills (including Microsoft, GSuite, and EMR).
• US work authorization required.

Responsibilities

• Proactively support highest-need patients with comprehensive assessments, telephonic check-ins, and in-person visits.
• Partner with patient and support persons to set goals, increase engagement, address barriers, and drive care-plan execution.
• Maintain knowledge of community resources and make referrals as appropriate.
• Navigate insurance benefits with the PRM to maximize plan benefits.
• Provide longitudinal and episodic care coordination to empower patients to manage their health and improve quality of life.
• Educate patients on supportive care options including advance care planning; provide goals-of-care counseling and advocacy.
• Provide psychoeducation on life-stage and disease-specific issues (e.g., dementia, aging, caregiver support).
• Collaborate with care teams to create solutions and spearhead interventions in complex psychosocial situations.
• Document MSW interventions clearly and timely for care-team visibility.
• Guide Community Health Workers on complex patient needs.
• Respond to crises with prioritization, triage, and multitasking.
• Other duties as assigned.

Skills

US work authorization

Spanish/Polish/Russian language skills

Proficient computer skills

EMR familiarity

Education

Master of Social Work (CSWE-accredited)

Tools

Electronic Medical Records (EMR)

Job description

Oak Street Health is seeking a Medical Social Worker to join their care teams, providing psychosocial assessments, advocacy, and comprehensive care coordination for high-risk patients and their caregivers. The MSW will collaborate with interdisciplinary teams to improve health outcomes and reduce hospitalizations.

Responsibilities include conducting assessments, coordinating care, navigating resources and benefits, and educating patients on support options, with emphasis on empowerment and