The Medical Social Worker is a key member of Oak Street Health Centers, contributing a unique and valuable perspective to care teams to support the psychosocial needs of our patients. In collaboration with the interdisciplinary care team, they will provide assessments, advocacy, and comprehensive care coordination services to our highest-risk patients and their caregivers to help them improve their health status and avoid hospitalizations. Core Responsibilities include proactively supporting highest-need patients by providing comprehensive assessments, telephonic check-ins, and in-person visits; partnering with patients and their support persons to identify goals, increase engagement in healthcare, address barriers, and drive care plan execution; maintaining extensive knowledge of community resources and making referrals; navigating patient insurance benefits; providing longitudinal and episodic comprehensive care coordination; educating patients on supportive care options and providing goals of care counseling; providing psychoeducation to patients and families; collaborating with care teams to generate solutions; completing documentation; providing clinical guidance to Community Health Workers; responding to crises and urgent needs; and other duties as assigned. The role reports to the Practice Manager. Required qualifications include a Master of Social Work degree from a CSWE-accredited school, licensure in the state where the center is located, fluency in relevant languages as needed, proficient computer skills, and US work authorization. Preferred qualifications include experience with complex care coordination, use of metrics and data, and medical social work experience in healthcare. The role requires motivation, problem-solving orientation, passion for working with Medicare-eligible populations, and embodying 'Oaky' values. Oak Street Health is focused on personalized primary care for older adults on Medicare, with a mission to improve health outcomes and quality of life.