Title: Medical Social Worker
The mission of Oak Street Health is to rebuild healthcare as it should be.
We are a rapidly growing, innovative company of community-based healthcare centers delivering higher quality health and wellness care that improves outcomes, manages medical costs and provides an unmatched experience for adults on Medicare.
The Oak Street model integrates outstanding clinical expertise, technology, and teamwork to deliver improved care quality and cost savings. These cost savings are then reinvested into care in our communities, creating a virtuous cycle of improving community health.
We are a national organization serving over 100,000 patients and we are growing rapidly. We are a diverse team of care providers, service team members, technologists, community outreach experts, business professionals, and more -- all dedicated to our Oaky Values and motivated by our mission. We're looking forward to getting to know you!
The Medical Social Worker is a key member of a clinic, contributing to multiple care teams to support the social service needs of our patients. As a part of the care management team, Medical Social Workers would be providing care to an underserved area of the community. In partnership with the care team, they will serve as a prevention specialist, providing assessment, advocacy, and case management services to individual patients and their caregivers, in an effort to help patients maintain or improve their health status and avoid hospitalizations. It will will be expected to carry a caseload, build relationships with Oak Street Health patients, manage patient's care plans, perform proactive phone and in-person outreach to our patients based on their care needs, complete assessments, participate in Care Team decision making, participate and lead weekly care team meetings, and generally coordinate all clinical and auxiliary services needed to provide a high quality health care experience from Oak Street Health.
Proactively support our highest need patients through telephonic check-ins, clinic visits
Partner with patients to identify their goals, increase engagement in care and reduce barriers to achieving healthcare goals and execution of their care plan
Facilitate patient referrals to community agencies and resources, under the direction of the provider and in line with Oak Street Health medical management efforts
Navigate Managed Care plans and resources to ensure mindful utilization
Provide community case management to increase patient ability to independently manage health conditions and reduce reliance on support services
Increase patient understanding of end-of-life options and prepare patients and their caregivers for potential challenges in end-of-life care
Conduct biopsychosocial assessments using evidence-based tools for patients in care
Participate in care team meetings, leading discussion around patients in his/her caseload
Complete case and progress documentation in a timely manner to allow for visibility into case status and productivity
Manage an assigned caseload while remaining in compliance with all internal and regulatory requirements (where delegated service is active)
Collaborate with internal care teams as well as external healthcare professionals, patient social supports and insurance resources to assess the patient's healthcare needs and ensure successful outcome of care plan goals
Scheduling, leading and maintenance of interdisciplinary care team (ICT) meetings (where delegated service is active)
Collaborate with internal and external behavioral health care team members and specialists when applicable
Conduct assessment(s) to identify individual patient needs and goals, develops a specific patient-centered care plan to address problems, sets goals and interventions as identified during the assessment
Forming relationships with patients and their caregivers to support prevention focused care and ED/ hospital diversion, where appropriate, and focusing interventions on reduction of avoidable hospital admissions, readmissions and ED visits
Maintain HIPAA standards and confidentiality of protected health information
Complete all activities and interventions outlined in the members care plan and ongoing monitoring of cases to ensure routine follow up and progression in their care plan goals
Assess patients' psychosocial needs and promotes access to community resources
Assist with the completion of applications to access eligible benefits
Partner with Care Team throughout managed patients' inpatient and post acute episodes of care
Maintain clear documentation of patient enrollment and progression through programs within program compliance timeframes
Practice in accordance with applicable laws and standards, and ethical principles
Perform other job duties as requested by Care Management leadership team
Participate in compliance audits for caseload (where delegated service is active)
What are we looking for?
Bachelor's degrees and/or two years of relevant health care experience required
Masters in Social Work required, LSW/LCSW required
Prior Care coordination or case management experience
Bilingual in Spanish or other languages spoken by people in the communities we serve
Experience with motivational interviewing, behavior change, health promotion, and coaching
Knowledge of payer managed care programs preferred
Strong communication skills and customer service orientation
Accomplished problem-solving skills and a highly flexible and accountable work ethic
Experience working with multiple software platforms, electronic health records, google suite, including gmail and google documents, spreadsheet development and navigation, data processing
Capacity to transport oneself to members' homes and facilities and comply with travel and mileage reimbursement policies
A positive and supportive attitude toward our patient population with the ability to exhibit Oak Street Health's values in daily interactions
Ability to work autonomously, follow through with delegated tasks, and be directly accountable for deliverables in a faced-paced environment
Outstanding verbal and written communication skills
A high-level of accountability and responsibility for the outcome of care
Excellent interpersonal and facilitation skills
Excellent organizational skills and ability to manage multiple priorities appropriately
Independent problem-solving skills
US work authorization
Someone who embodies being "Oaky"
What does being "Oaky" look like?
Radiating positive energy
Assuming good intentions
Creating an unmatched patient experience
Driving clinical excellence
Taking ownership and delivering results
Why Oak Street?
Oak Street Health offers our coworkers the opportunity to be at the forefront of a revolution in healthcare, as well as:
Collaborative and energetic culture
Fast-paced and innovative environment
Competitive benefits including paid vacation and sick time, generous 401K match with immediate vesting, and health benefits
Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply to oakstreethealth.com/careers.
Oak Street Health Inc.