Company: Oak Street Health

Title: Regional Lead Social Worker 

Location: Various

Oak Street Health is 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 in medically underserved communities. By providing holistic, comprehensive and integrated care right in our patients' communities, we can help keep them healthy and reinvest cost savings in further care for those same communities and others. Since 2013, Oak Street Health has brought its singular approach to tens of thousands of people across the nation. With an ambitious growth trajectory, Oak Street Health is attracting and cultivating team members who embody Oak Street values and are passionate about our mission to rebuild healthcare as it should be.

For more information, visit www.oakstreethealth.com.

Role Description:

Oak Street Health takes a team-based approach to providing outstanding patient care. Our Care Teams, consisting of a Physician, Nurse Practitioner, Nurse, Medical Assistants, and Medical Social Workers, build individual relationships across a panel of 500-800 patients. The Care Team is responsible for delivering excellent, high-touch, primary care, and coordinating the care of our patients throughout the healthcare delivery system.

Regional Lead Social Workers are an important part of our Care Teams, providing support to other clinic social workers throughout the region. Due to the level of responsibility of the Lead Social Worker, high levels of flexibility, attention to detail, being an advocate for the social work profession, and problem solving are required to be successful.

Core Responsibilities:

Social Work Leadership

Building and cultivating relationships with our patients and community partners

Leading social work interviewing and hiring initiatives for the region

Assisting local leadership team with expanding social work services in expansion markets/centers

Providing training and orientation to new social workers

Clinical case consultation support to social work staff

Conducting soft audits of care plans and chart documentation

Administrative support on social work driven modules and technology

Administrative support on adopted care management model

Providing LCSW (or state equivalent licensure) supervision to staff (where applicable)

Working as a liaison between organizational initiatives and social workers to ensure execution of assignments and responsibilities are adequately completed  

Assisting social workers in aligning and carrying out organizational goals and metrics 

May assist clinic social workers with home visitation needs

Partners with other leaders to discuss social work initiatives, concerns, needs, and updates

Local Advance Directive Expert

Coordinating and overseeing practicum/internship programs/placements (where applicable)

Coordinating in-services for social workers in region on established cadance

A Lead Social Worker may intermittently provide patient care by:

Performing proactive outreach to patients based on their care needs

Conducting bio-psychosocial assessments through our AIMS care management model

Co-managing interdisciplinary care plans with care team partners 

Medication assistance (financial assistance)

Home visitations may be necessary

Sending referrals to external resources (home health, transportation services, mental health agencies, local, state, and federal aid agencies, etc)

Providing patient education/advocacy

Brief Crisis Intervention/Therapy (when applicable) 

Assessing patients for referral to BHS services and external mental health services

Leading case plan discussions 

Other duties as assigned

What are we looking for?

Minimum of 2 years of case coordination/care management experience, including conducting home visits and providing telephonic support

Clinical Licensure required at time of hire 

Demonstrates supportive and welcoming attitude toward our patient population of older and disabled adults

An eagerness to build relationships with patients, their families, and the communities we serve

A problem-solving orientation with a flexible and positive attitude

Bilingual fluency preferred-depending on community served

Proficient PC skills 

US work authorization

Someone who embodies being 'Oaky.'

What does being 'Oaky' look like?

Radiating positive energy

Assuming good intentions

Creating an unmatched patient experience

Driving clinical excellence

Taking ownership and delivering results

Being scrappy

Why 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 culture

Fast-paced and innovative environment

Competitive benefits including paid vacation and sick time, generous 401K match with immediate vesting, and health benefits

Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply to oakstreethealth.com/careers.