About Job
- 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 (if necessary) 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, as appropriate, to help ensure the patient's healthcare and psychosocial needs are met.
- Navigate patient insurance benefits in collaboration with the Patient Relations Manager (PRM) to ensure mindful utilization and maximization of plan benefits
- Provide both longitudinal and episodic comprehensive care coordination with the ultimate goal of empowering patients to independently manage their health conditions and have increased quality of life.
- Educate patients on supportive care options (including advance care planning and end-of-life care) 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, including dementia, adjustment to illness, aging, caregiver support, etc.
- Meet with care teams to collaborate and generate creative solutions to patient issues, and spearhead intervention in situations with complex psychosocial dynamics.
- Complete concise and comprehensive documentation on time to ensure that all care team members have visibility into the status of MSW interventions
- Partner with Community Health Workers and provide clinical guidance and consultation regarding complex patient needs to these team members.
- Respond to crises and urgent needs with the keen ability to prioritize work, triage situations, and multitask.
- Other duties as assigned.
- Master of Social Work degree required from a school of social work 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 people in the communities we serve (where necessary)
- Proficient computer skills (including Microsoft, GSuite, and electronic medical records)
- US work authorization
- 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
- Motivated, experienced social workers with a problem-solving orientation and a flexible and positive attitude who are driven to improve the lives of the individuals that OSH serves.
- Passion for working with Medicare-eligible populations, including older adults, adults with disabilities, and adults with severe and persistent mental illness
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