- Proactively support highest-need patients through telephonic check-ins and clinic visits
- Collaborate with patients to define goals, boost engagement in care, and overcome barriers to achieving healthcare goals
- Guide patient referrals to community organizations and resources, following provider direction and aligned with Oak Street Health medical management efforts
- Navigate Managed Care plans and resources to ensure mindful utilization
- Provide community case management to enhance patient capacity to autonomously manage health conditions and reduce reliance on support services
- Enhance patient comprehension of end-of-life choices and prepare patients and their caregivers for potential end-of-life care challenges
- Perform biopsychosocial assessments utilizing evidence-based tools for patients under care
- Engage in care team meetings, leading discussions about patients in the caseload
- Record case details and progress promptly to allow visibility into case status and productivity
- Handle an assigned caseload while complying with all internal and regulatory requirements
- Collaborate with internal care teams, external healthcare professionals, patient social support systems, and insurance resources to evaluate patient healthcare needs and ensure care plan goal achievement
- Organize and lead interdisciplinary care team meetings
- Cooperate with internal and external behavioral healthcare team members and specialists when needed
- Perform assessments to identify individual patient needs and goals, devise patient-centered care plans, set goals and interventions based on assessment outcomes
- Establish connections with patients and their caregivers to encourage prevention-focused care and ED/hospital diversion when suitable, with a focus on reducing avoidable hospital admissions, readmissions, and ED visits
- Uphold HIPAA standards and safeguard the confidentiality of protected health information
- Fulfill all activities and interventions outlined in the member's care plan, ensuring routine follow-up and progress toward care plan goals
- Evaluate patients' psychosoci
- Bachelor's degrees and/or two years of relevant health care experience
- Masters in Social Work, LSW/LCSW required
- Previous Care coordination or case management experience
- Bilingual in Spanish or other languages spoken by the communities we serve
- Proficiency in motivational interviewing, behavior change, health promotion, and coaching
- Familiarity with payer managed care programs preferred
- Effective communication skills and focus on customer service
- Strong problem-solving skills and a flexible work ethic
- Experience with various software platforms, electronic health records, Google Suite, including Gmail and Google Documents, spreadsheet management and navigation, data processing
- Ability to travel to members' homes and facilities and adhere to travel policies
- Positive and supportive attitude toward our patient population, reflecting Oak Street Health's values in daily interactions
- Capability to work independently, complete delegated tasks, and be accountable for deliverables in a fast-paced setting
- Exceptional verbal and written communication abilities
- High level of accountability and responsibility for care outcomes
- Superior interpersonal and facilitation skills
- Strong organizational skills and ability to manage multiple priorities effectively
- Independent problem-solving capabilities
- Valid US work authorization
- Shares the essence of being 'Oaky'
- Radiates positive energy
- Assumes good intentions
- Creates an exceptional patient experience
- Drives clinical excellence
- Takes ownership and delivers results
- Demonstrates resourcefulness
- Collaborative and vibrant work culture
- Fast-paced and inventive atmosphere
- Competitive benefits including paid time off, 401K match, and health benefits
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Medical Social Worker - Bronx, NY, United States - Oak Street Health Inc.
Description
Title: Medical Social Worker
Location: Various
The salary range for this position is $60,820 to $90,580 annually excluding additional compensation like bonuses and overtime.
Company Description
The goal of Oak Street Health is to transform healthcare for the better.
We are an expanding, creative organization of community-focused healthcare centers providing superior health and wellness care that enhances outcomes, manages medical expenses, and offers an unparalleled experience for adults covered by Medicare.
The Oak Street model combines exceptional clinical knowledge, technology, and teamwork to deliver enhanced care quality and cost efficiency. These cost savings are then reinvested into community care, establishing a positive cycle of enhancing community health.We are a national group serving over 100,000 patients and experiencing significant growth.
We are a diverse team of healthcare providers, support staff, technologists, community engagement specialists, business experts, and more, all committed to our Oaky Values and inspired by our mission.
We are excited to connect with you.Role Description
The Medical Social Worker is a crucial member of a clinic, contributing to multiple care teams to address the social service needs of our patients.
As part of the care management team, Medical Social Workers will offer care to an underserved community segment.
In collaboration with the care team, they will function as a prevention specialist, providing evaluation, advocacy, and case management services to individual patients and their caregivers, striving to help patients sustain or enhance their health and prevent hospitalizations.
The role entails managing a caseload, establishing relationships with Oak Street Health patients, overseeing patients' care plans, conducting proactive outreach to our patients based on their needs, conducting assessments, participating in Care Team decision-making, leading weekly care team meetings, and coordinating all clinical and auxiliary services necessary to provide a top-quality healthcare experience from Oak Street Health.
Responsibilities
What We're Seeking
'Oaky' Characteristics
Why Oak Street?
Joining Oak Street Health provides our employees the chance to participate in a healthcare evolution and offers:
Oak Street Health is an equal opportunity employer. We celebrate diversity and encourage all interested candidates to apply.
