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Oak Street Health - Hempstead, NY
posted 2 months ago
About the position
The Medical Social Worker at Oak Street Health Centers plays a crucial role in supporting the psychosocial needs of patients, particularly those at high risk. This position involves collaboration with interdisciplinary care teams to provide assessments, advocacy, and comprehensive care coordination services aimed at improving health outcomes and preventing hospitalizations. The role emphasizes patient engagement, resource navigation, and crisis response, ensuring that patients receive holistic care tailored to their individual needs.
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 in their healthcare, address barriers, and drive the execution of their care plan.
- Maintain extensive knowledge of community resources and make referrals to meet patients' healthcare and psychosocial needs.
- Navigate patient insurance benefits in collaboration with the Patient Relations Manager to ensure mindful utilization and maximization of plan benefits.
- Provide both longitudinal and episodic comprehensive care coordination to empower patients to manage their health conditions independently.
- Educate patients on supportive care options and provide goals of care counseling, support, and advocacy at all stages of the patient journey.
- Provide psychoeducation to patients and families surrounding life stage and disease-specific issues.
- Meet with care teams to collaborate and generate creative solutions to patient issues, and spearhead intervention in complex psychosocial dynamics.
- Complete concise and comprehensive documentation on time to ensure visibility into the status of MSW interventions.
- Partner with Community Health Workers and provide clinical guidance regarding complex patient needs.
- Respond to crises and urgent needs with the ability to prioritize work, triage situations, and multitask.
- Ability to travel to assigned centers when needed as directed by manager.
Requirements
- Master of Social Work degree from a school accredited by the Council on Social Work Education (CSWE).
- Minimally licensed in the state where OSH Center is located.
- Fluency in Spanish, Polish, Russian, or other languages spoken by the communities served (where necessary).
- Proficient computer skills including Microsoft, GSuite, and electronic medical records.
- Access to personal transportation with a valid driver's license required.
- US work authorization.
Nice-to-haves
- Prior experience with complex care coordination and/or population healthcare management.
- Familiarity with using metrics and data to guide practice and drive outcomes.
- Minimum one year of medical social work experience in a healthcare environment, preferably within the last two years.
- Experience working on a multidisciplinary team of other healthcare providers.
Benefits
- Paid vacation and sick time.
- Investment/retirement 401K match options.
- Health insurance, vision, and dental benefits.
