Medical Social Worker
Core
Provide psychosocial assessments, advocacy, and care coordination for high-risk patients to improve health status and prevent hospitalizations.
Role type
Medical Social Worker (Clinical IC)
Builds
Patient care plans and community resource referrals
Domain
Healthcare / Geriatrics / Chronic Disease Management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Psychosocial assessment, care coordination, community resource navigation, insurance benefits navigation, crisis triage, psychoeducation, documentation, interdisciplinary collaboration
Preferred skills
Complex care coordination, population healthcare management, data-driven practice, multidisciplinary team experience
Technologies
Microsoft Office, GSuite, Electronic Medical Records (EMR)
Responsibilities
Conduct comprehensive assessments and telephonic/in-person check-ins; Partner with patients to identify goals and address barriers; Maintain knowledge of community resources and make referrals; Navigate patient insurance benefits; Provide longitudinal care coordination and goals of care counseling; Educate patients on disease-specific issues and supportive care options; Collaborate with care teams to generate solutions for complex psychosocial dynamics; Respond to crises and urgent needs; Provide clinical guidance to Community Health Workers.
Seniority
Mid-level, hands-on IC