House Calls Behavioral Health Specialist (LMMSW Required, LMSW Preferred)

Providers Detroit, Michigan


Company: Oak Street Health

Title: House Calls Behavioral Health Specialist

Location: Varies

Company Description

The mission of Oak Street Health is to rebuild healthcare as it should be. 

We are a rapidly growing, innovative company of community-based healthcare centers delivering higher quality health and wellness care that improves outcomes, manages medical costs and provides an unmatched experience for adults on Medicare.

The Oak Street model integrates outstanding clinical expertise, technology, and teamwork to deliver improved care quality and cost savings. These cost savings are then reinvested into care in our communities, creating a virtuous cycle of improving community health. 

We are a national organization serving over 100,000 patients and we are growing rapidly. We are a diverse team of care providers, service team members, technologists, community outreach experts, business professionals, and more -- all dedicated to our Oaky Values and motivated by our mission. We’re looking forward to getting to know you!

For more information, visit


Role Description:

The House Calls Behavioral Health Specialist is a key resource for the At-Home Care Teams. The At-Home Care Teams deliver high-touch, high-quality primary care to our Oak Street Health’s highest risk patients.  In this role, the LCSW will coordinate, support and perform community based, behavioral healthcare for these patients and will be a key contributor and collaborator within the care team to support care coordination and all other needs. 


Core Responsibilities:

  • Collaborate with OSH At-Home providers and Psychiatric Consult to identify and intervene with patients with psychosocial, community resource, and/or behavioral health needs

  • Function as the behavioral health and community resource expert on the OSH At-Home care team and actively contribute during team meetings

  • Facilitate goals of care and advance care planning discussions with patients and families in collaboration with their medical providers

  • Manage referrals for patients requiring specialized services through resource connections

  • Actively manage the shared BH registry to track individual patient progress of treatment toward target

  • Prepare and attend weekly registry review sessions with Psychiatric consult

  • Function as the behavioral health and community resource expert on the OSH At-Home care team and actively contribute during interdisciplinary team meetings

  • Screen and assess patients for common mental health and substance use disorders

  • Develop care plans and facilitate referrals to external resources

  • Provide short-term counseling and evidence-based treatments within the Collaborative Care Model

  • Accurate and timely documentation of patient encounters in Oak Street’s electronic medical record

  • Other duties, as assigned 


What are we looking for?

We’re looking for motivated, licensed clinical social workers with:

  • Comfort and ability to work in a variety of environments, including patients’ homes

  • Demonstrated ability to collaborate effectively in a team setting

  • Comfort supporting patients who are facing significant health, psychosocial and/or mental health issues

  • Experience with performing comprehensive biopsychosocial health, mental health and substance abuse disorder assessments

  • Experience with assessment and treatment planning for those with common mental health and/or substance use disorders and complex psychosocial needs

  • Working knowledge of differential diagnosis and psychosocial treatments of common mental health and/or substance use disorders 

  • Familiarity with brief, structured intervention techniques (e.g., Motivational Interviewing, Behavioral Activation)

  • Proficient PC skills

  • US work authorization

  • Someone who embodies being “Oaky”.


What does being “Oaky” look like?

  • Radiating positive energy

  • Assuming good intentions

  • Creating an unmatched patient experience

  • Driving clinical excellence

  • Taking ownership and delivering results

  • Being scrappy


Why Oak Street?

Oak Street Health offers our coworkers the opportunity to be at the forefront of a revolution in healthcare, as well as:

  • Collaborative and energetic culture

  • Fast-paced and innovative environment

  • Competitive benefits including paid vacation and sick time, generous 401K match with immediate vesting, and health benefits

Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply to