About The Position

The House Calls Behavioral Health Specialist is a key resource for the At-Home Care Teams. The At-Home Care Teams deliver high-touch, high-quality primary care to our Oak Street Health's highest risk patients. In this role, the LCSW will coordinate, support and perform community based, behavioral healthcare for these patients and will be a key contributor and collaborator within the care team to support care coordination and all other needs.

Requirements

  • Comfort and ability to work in a variety of environments, including patients' homes
  • Demonstrated ability to collaborate effectively in a team setting
  • Comfort supporting patients who are facing significant health, psychosocial and/or mental health issues
  • Experience with performing comprehensive biopsychosocial health, mental health and substance abuse disorder assessments
  • Experience with assessment and treatment planning for those with common mental health and/or substance use disorders and complex psychosocial needs
  • Working knowledge of differential diagnosis and psychosocial treatments of common mental health and/or substance use disorders
  • Familiarity with brief, structured intervention techniques (e.g., Motivational Interviewing, Behavioral Activation)
  • Proficient PC skills
  • US work authorization

Nice To Haves

  • Someone who embodies being 'Oaky'

Responsibilities

  • Collaborate with OSH At-Home providers and Psychiatric Consult to identify and intervene with patients with psychosocial, community resource, and/or behavioral health needs
  • Function as the behavioral health and community resource expert on the OSH At-Home care team and actively contribute during team meetings
  • Facilitate goals of care and advance care planning discussions with patients and families in collaboration with their medical providers
  • Manage referrals for patients requiring specialized services through resource connections
  • Actively manage the shared BH registry to track individual patient progress of treatment toward target
  • Prepare and attend weekly registry review sessions with Psychiatric consult
  • Screen and assess patients for common mental health and substance use disorders
  • Develop care plans and facilitate referrals to external resources
  • Provide short-term counseling and evidence-based treatments within the Collaborative Care Model
  • Accurate and timely documentation of patient encounters in Oak Street's electronic medical record
  • Other duties, as assigned

Benefits

  • Competitive benefits including paid vacation and sick time
  • Generous 401K match with immediate vesting
  • Health benefits
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