Lead Social Worker (Ohio, Western Pennsylvania, Virginia)

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As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Job Description

Company: Oak Street Health

Title: Lead Social Worker  

Company Description

Oak Street Health is a rapidly growing company of primary care centers for adults on Medicare in medically-underserved communities where there is little to no quality healthcare. Oak Street’s care is based on an entirely new model that is based on value for its patients, not on volume of services. The company is accountable for its patients’ health, spending more than twice as long with its patients and taking on the risks and costs of their care. For more information, visit  http://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,  Medical Social Workers, and Community Health 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, supporting other clinic Medical Social Workers and Community Health Workers throughout the region. Due to the level of responsibility of the Lead Social Worker, high levels of flexibility, energy, attention to detail, being an advocate for the social work profession, and problem solving are required to be successful. Specific responsibilities include: 

Social Work Leadership

• Building and cultivating relationships with our patients and community partners

• Leading social work and community health worker interviewing and hiring initiatives for the region

• Assisting regional leadership team with expanding social work and community health worker services in expansion markets/centers

• Providing training and orientation to new social workers and community health workers

• Clinical case consultation support to care management staff

• Conducting soft audits of care plans and chart documentation

• Administrative support on care management 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 regional care management staff to ensure execution of assignments and responsibilities are adequately completed  

• Assisting regional care management staff in aligning and carrying out organizational goals and metrics 

• Partners with other leaders to discuss care management initiatives, concerns, needs, and updates

• Expert in local advance directive options and documentation requirements, with the ability to coach social workers on utilization and competency

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

• Coordinates in-services for regional care management staff on established cadence

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 

• Sending referrals to external resources (home health, tr