Ruel Samuels

Medical Social Worker @Oak Street Health, part of CVS Health

Raleigh-Durham-Chapel Hill, NC, US

The Medical Social Worker is a key member of a clinic, contributing to multiple care teams to support the social service needs of our patients•As a part of the care management team, Medical Social Workers would be providing care to an underserved area of the community•In partnership with the care team, they 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•It will will be expected to carry a caseload, build relationships with Oak Street Health patients, manage patient’s care plans, perform proactive phone and in-person outreach to our patients based on their care needs, complete assessments, participate in Care Team decision making, participate and lead weekly care team meetings, and generally coordinate all clinical and auxiliary services needed to provide a high quality health care experience from Oak Street Health•Proactively support our highest need patients through telephonic check-ins, clinic visits•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 the 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•Conduct biopsychosocial assessments using evidence-based tools for patients in care•Participate in care team meetings, leading discussion around patients in his/her caseload