Medical Social Worker (Bilingual Spanish Preferred)
Core
Provide assessments, advocacy, and comprehensive care coordination to support the psychosocial needs of highest-risk patients and their caregivers to improve health status and avoid hospitalizations.
Role type
Medical Social Worker (IC)
Builds
Patient care plans and care coordination services for high-risk populations
Domain
Healthcare / Social 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 and episodic care coordination; Educate patients on supportive care and end-of-life planning; Collaborate with care teams to generate solutions for complex psychosocial dynamics; Complete documentation; Provide clinical guidance to Community Health Workers; Respond to crises and urgent needs.
Seniority
Mid-level, hands-on IC