Medical Social Worker: High-Impact Care Coordinator

8350 Oak Street Health MSO LLC; Fairmont (MN); On-site; USD 51,000 - 111,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Wellness programs

Other resources

Job summary

Oak Street Health is seeking a Medical Social Worker to join our care teams. You will assess psychosocial needs, coordinate services, and advocate for patients with complex health and social needs to reduce hospitalizations.

The role emphasizes collaboration with interdisciplinary teams, community resources, and education for patients and families. A CSWE-accredited MSW and state licensure are required, with language skills valued.

Qualifications

• MSW degree from CSWE-accredited school.
• Active state license where OSH Center is located.
• Fluency in Spanish, Polish, Russian, or other local languages.
• Proficient with Microsoft Office, Google Workspace, and EMR systems.
• U.S. work authorization.

Responsibilities

• Provide comprehensive assessments, telephonic check-ins, and in-person visits for high-need patients.
• Collaborate with care teams to identify goals and execute care plans.
• Refer to community resources and coordinate referrals.
• Navigate insurance benefits with PRM to maximize coverage.
• Coordinate longitudinally and episodically to empower self-management.
• Educate on supportive care options and goals of care counseling.
• Provide psychoeducation on dementia, aging, illness adjustment, caregiver support.
• Collaborate with care teams to develop solutions for psychosocial issues.
• Document care interventions concisely and timely.
• Partner with Community Health Workers for complex patient needs.
• Respond to crises and urgent needs, prioritize, triage, multitask.
• Other duties as assigned.

Skills

Multilingual communication

Care coordination

Education

Master of Social Work

State licensure

Tools

Microsoft Office

Google Workspace

EMR systems

Job description

Oak Street Health is seeking a Medical Social Worker to join our care teams. You will assess psychosocial needs, coordinate services, and advocate for patients with complex health and social needs to reduce hospitalizations.

The role emphasizes collaboration with interdisciplinary teams, community resources, and education for patients and families. A CSWE-accredited MSW and state licensure are required, with language skills valued.