Medical Social Worker, Home Based Care Team

Oak Street Health Chicago , IL 60602

Posted 3 weeks ago

Medical Social Worker (MSW/LCSW) - Home Based Care Team

Role Description

Oak Street Health delivers high-quality primary care to Medicare patients in neighborhood centers - and beyond when needed. The Social Worker is a member of the Oak Street Health Home Based Care Team and supports high-risk, high-need patients and their caregivers during discharge and post-discharge. This role partners with Transitions RNs, House Calls Nurse Practitioners and Medical Assistants, as well as clinic-based primary care teams. The Social Worker is responsible for a limited number of patients, delivered in the home and by phone.

Core functions include:

  • Identify psychosocial and environmental barriers impacting patients' health

  • Provide effective and reliable support to patients and caregivers in the home, by phone, or in facilities

  • Facilitate goals of care / Advanced Care Planning conversations

  • Facilitate patient referrals to community agencies and resources

What we're looking for:

  • Motivated, flexible and experienced medical social worker

  • Strong problem-solving orientation and a flexible and positive attitude

  • Prior independent care management or case coordination experience

  • Comfort working in various settings, including in patient homes

  • Enthusiasm for working with high-need patients

  • Comfort with high degrees of ambiguity

  • Skilled collaborator who thrives in a team environment


  • Masters in Social Work required, preferably from a school of social work accredited by the Council on Social Work Education

  • LCSW

  • Minimum one year of medical social work experience

  • Daily access to a vehicle with valid license, insurance, and strong driving record

  • Flexibility to travel around Chicagoland

  • Bilingual (English and Spanish) a plus

  • US work authorization

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Medical Social Worker, Home Based Care Team

Oak Street Health