Medical Social Worker: Care Coordination & Patient Advocacy

Society for Social Work and Research; Richmond (VA); On-site; USD 47,000 - 101,000; Full time

Job summary

Oak Street Health is seeking a Medical Social Worker to support psychosocial needs of patients within our health centers. You will work with interdisciplinary teams to assess, advocate, and coordinate care for high-risk patients and their caregivers to improve health outcomes and reduce hospitalizations.

Responsibilities include conducting assessments, planning with patients and families, navigating benefits, and providing education and crisis response as part of a collaborative care approach.

Qualifications

• MSW degree from CSWE-accredited program.
• Minimally licensed in the state of the OSH Center location.
• Fluency in languages spoken by communities served.
• Proficient computer skills including EMR.

Responsibilities

• Perform comprehensive assessments and telephonic check-ins with high-need patients.
• Coordinate care plans with patients, families, and care teams.
• Identify barriers and arrange referrals to support services.
• Navigate insurance benefits with the PRM for benefit maximization.
• Provide longitudinal and episodic care coordination to improve outcomes.
• Educate on care options and goals of care across the patient journey.
• Deliver psychoeducation to patients and families on life stage issues.
• Collaborate with care teams to devise solutions for complex psychosocial needs.
• Maintain concise documentation for visibility across the care team.
• Guide Community Health Workers with clinical consultation.

Skills

Spanish language

Communication skills

Education

Master of Social Work degree

Tools

Microsoft Office

GSuite

Electronic Medical Records

Job description

Oak Street Health is seeking a Medical Social Worker to support psychosocial needs of patients within our health centers. You will work with interdisciplinary teams to assess, advocate, and coordinate care for high-risk patients and their caregivers to improve health outcomes and reduce hospitalizations.

Responsibilities include conducting assessments, planning with patients and families, navigating benefits, and providing education and crisis response as part of a collaborative care approach.