Medical Social Worker (LSW) (Bi-lingual Spanish ...

Description Position at Oak Street Health Title: Medical Social WorkerLocation: Bronx, NY (Soundview)Company DescriptionThe 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 moreall dedicated to our Oaky Values and motivated by our mission. We're looking forward to getting to know you!Role DescriptionThe 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. ResponsibilitiesProactively support our highest need patients through telephonic check-ins, clinic visitsPartner with patients to identify their goals, increase engagement in care and reduce barriers to achieving healthcare goals and execution of their care planFacilitate patient referrals to community agencies and resources, under the direction of the provider and in line with Oak Street Health medical management effortsNavigate Managed Care plans and resources to ensure mindful utilizationProvide community case management to increase patient ability to independently manage health conditions and reduce reliance on support servicesIncrease patient understanding of end-of-life options and prepare patients and their caregivers for potential challenges in end-of-life careConduct biopsychosocial assessments using evidence-based tools for patients in careParticipate in care team meetings, leading discussion around patients in hisher caseloadComplete case and progress documentation in a timely manner to allow for visibility into case status and productivityManage 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 goalsScheduling, 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 applicableConduct 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 assessmentForming 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 visitsMaintain HIPAA standards and confidentiality of protected health informationComplete 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 goalsAssess patients' psychosocial needs and promotes access to community resourcesAssist with the completion of applications to access eligible benefitsPartner with Care Team throughout managed patients' inpatient and post acute episodes of careMaintain clear documentation of patient enrollment and progression through programs within program compliance timeframesPractice in accordance with applicable laws and standards, and ethical principlesPerform other job duties as requested by Care Management leadership teamParticipate in compliance audits for caseload (where delegated service is active)What are we looking for?Bachelor's degrees andor two years of relevant health care experience requiredMasters in Social Work required, LSWLCSW requiredPrior Care coordination or case management experienceBilingual in Spanish or other languages spoken by people in the communities we serveExperience with motivational interviewing, behavior change, health promotion, and coachingKnowledge of payer managed care programs preferredStrong communication skills and customer service orientationAccomplished problem-solving skills and a highly flexible and accountable work ethicExperience working with multiple software platforms, electronic health records, google suite, including gmail and google documents, spreadsheet development and navigation, data processingCapacity to transport oneself to members' homes and facilities and comply with travel and mileage reimbursement policiesA positive and supportive attitude toward our patient population with the ability to exhibit Oak Street Health's values in daily interactionsAbility to work autonomously, follow through with delegated tasks, and be directly accountable for deliverables in a faced-paced environmentOutstanding verbal and written communication skillsA high-level of accountability and responsibility for the outcome of careExcellent interpersonal and facilitation skillsExcellent organizational skills and ability to manage multiple priorities appropriatelyIndependent problem-solving skillsUS work authorizationSomeone who embodies being 'Oaky'What does being 'Oaky' look like?Radiating positive energyAssuming good intentionsCreating an unmatched patient experienceDriving clinical excellenceTaking ownership and delivering resultsBeing scrappyWhy 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 cultureFast-paced and innovative environmentCompetitive benefits including paid vacation and sick time, generous 401K match with immediate vesting, and health benefitsOak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply to careers.

Created: 2025-02-16