Description

Medical Social Worker – Oak Street Health

Oak Street Health, a network of primary care centers serving adults on Medicare in underserved communities, is seeking a Medical Social Worker. In this patient-centered, team-based role, you will complete psychosocial assessments, address social determinants of health, and coordinate community resources to support vulnerable patients. You’ll provide brief counseling, crisis intervention, and care planning while collaborating closely with clinicians to improve outcomes. Oak Street Health offers a supportive, inclusive environment with opportunities for professional growth and meaningful impact on community health.
Conduct comprehensive psychosocial assessments for Medicare patients in primary care settings.
Develop and implement patient-centered care plans addressing social determinants of health.
Coordinate community resources, benefits, and social services to support patient stability and adherence.
Provide short-term counseling, crisis intervention, and support to patients and families.
Collaborate closely with physicians, nurses, and care teams in a team-based care model.
Advocate for patients in underserved communities to improve access to healthcare and social support.
Document interventions and outcomes in the EHR accurately and in a timely manner.
Participate in quality improvement initiatives and population health programs.
Educate patients and caregivers on coping strategies, community resources, and care options.
Contribute to an inclusive, collaborative culture aligned with Oak Street Health’s mission.
Psychosocial assessment
Care coordination
Crisis intervention
Community resource navigation
Motivational interviewing
Electronic health records (EHR) documentation
Interdisciplinary teamwork
Discharge planning
Patient and family education
Cultural competence
Medical Insurance
Dental Insurance
Vision Insurance
Life Insurance
401k
Licensed Clinical Social Worker (LCSW) or equivalent state license
Master of Social Work (MSW) from accredited program
Training in motivational interviewing
Certification in case management (e.g., CCM) preferred
Experience with electronic health records (EHR)