Medical Social Worker: Care Coordination & Advocacy

Oak Street Health; Warwick (RI); On-site; USD 51,000 - 111,000; Full time

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Insurance

Retirement Savings

Job summary

Oak Street Health is hiring a Medical Social Worker to support psychosocial needs of high-risk patients, coordinating care with interdisciplinary teams and guiding families through complex care plans.

The role emphasizes assessment, advocacy, and extensive coordination to reduce hospitalizations and improve quality of life in a community health setting. Fluent in desired languages is preferred, with state licensure and CSWE-accredited MSW preferred.

Qualifications

• Master of Social Work degree from CSWE-accredited program.
• Licensed in the state where Oak Street Health Center is located (minimum)
• Fluency in Spanish, Polish, Russian, or other community languages

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 to identify goals, increase engagement, address barriers, and drive the care plan.
• Maintain knowledge of community resources and referrals to meet healthcare and psychosocial needs.
• Navigate insurance benefits with the PRM to ensure mindful utilization and benefits maximization.
• Provide longitudinal and episodic care coordination to empower patients to manage health conditions and quality of life.
• Educate patients on supportive care options and provide goals of care counseling and advocacy.
• Provide psychoeducation to patients and families on life stage and disease-specific issues.
• Collaborate with care teams to generate solutions for complex psychosocial dynamics.
• Complete concise documentation to ensure visibility of MSW interventions.
• Partner with Community Health Workers to provide clinical guidance.
• Respond to crises with prioritization and multitasking.
• Other duties as assigned.

Skills

Multilingual Spanish/Polish/Russian

US work authorization

Computer skills

Education

MSW degree (CSWE-accredited)

Tools

Microsoft Office

G Suite

Job description

Oak Street Health is hiring a Medical Social Worker to support psychosocial needs of high-risk patients, coordinating care with interdisciplinary teams and guiding families through complex care plans.

The role emphasizes assessment, advocacy, and extensive coordination to reduce hospitalizations and improve quality of life in a community health setting. Fluent in desired languages is preferred, with state licensure and CSWE-accredited MSW preferred.