Medical Social Worker

Social WorkerAt CVS Health, we are building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. 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. The Social Worker is a key member of a clinic, contributing to multiple care teams to support the social service needs of our patients. In partnership with the care team, s/he will serve as a prevention specialist, providing assessment, advocacy, and case management services to individual patients and their caregivers, in an effort to help patients maintain or improve their health status and avoid hospitalizations. Core functions of the role include: Proactively support our highest need patients through telephonic check-ins, clinic visits, and home visits (with and without a clinician) Partner with patients to identify their goals, increase engagement in care and reduce barriers to achieving healthcare goals and execution of their care plan Facilitate patient referrals to community agencies and resources, under direction of the provider and in line with Oak Street Health medical management efforts Navigate Managed Care plans and resources to ensure mindful utilization Provide community case management to increase patient ability to independently manage health conditions and reduce reliance on support services Increase patient understanding of end-of-life options and prepare patients and their caregivers for potential challenges in end-of-life care Lead patient and caregiver support groups focused on specific topics such as living with chronic illness, disease-specific education, aging with dignity, caregiver coaching, etc. Participate in care team meetings, leading discussion around patients in his/her caseload Complete case and progress documentation in a timely manner to allow for visibility into case status and productivity Anticipated Weekly Hours:40 Time Type: Full time