Job Description
At CVS Health, we're 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.
Company: Oak Street Health
Title: Behavioral Health Specialist, House Calls Program
Location: Indianapolis, IN
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 .
Program Overview
Oak Street Health@HOME delivers high-quality primary care to Medicare patients in their home. The @HOME program takes a team-based approach to providing outstanding patient care. Our Care Teams - consisting of a Provider, Medical Assistant/Scribe (CIS/MA), Behavioral Health Specialist (BHS) and Mobile Operations Coordinator (MOC) - build individual relationships across a panel of about 75 patients, seen monthly. The Care Team is responsible for delivering excellent, high-touch primary care, and coordinating the care of our patients throughout the healthcare delivery system.
Role Description
The House Calls Behavioral Health Specialist (BHS) is a key resource, contributing a unique and valuable perspective to care teams to support the psychosocial and behavioral needs of our patients. In this role, the Licensed Clinical Social Worker (LCSW) will provide social services and evidence-based short-term psychotherapy to home based patients.They will assess needs of patients, review goals of care, make referrals to appropriate behavioral health resources and specialists, provide short-term counseling and evidence-based treatments as indicated, advocate, assist with advanced care planning/end of life conversations, and coordinate comprehensive care services to our highest-risk patients and their caregivers to help them improve their health status and avoid unnecessary hospitalizations.
Core Responsibilities
Support our highest-need patients by providing comprehensive assessments, telephonic check-ins, and in-person visits.
Collaborate with medical providers to proactively identify and intervene with patients with psychosocial, community resource, and/or behavioral health needs
Partner with the patient and their support persons (if necessary) to identify goals, increase engagement in their healthcare, address barriers, and drive the execution of their care plan.
Maintain extensive knowledge of community resources and make referrals, as appropriate, to help ensure the patient's healthcare and psychosocial needs are met.
Screen and assess patients for common mental health and substance use disorders
Provide short-term counseling and evidence-based treatments within the Collaborative Care Model
Provide psychoeducation to patients and families surrounding life stage and disease-specific issues, including dementia, adjustment to illness, aging, caregiver support, etc.
Provide or facilitate referrals to Oak Street's psychiatric consultant and/or external resources, as needed
Facilitate supportive care options (including advance care planning, goals of care and end-of-life care) and provide goals of care counseling, support, guidance and advocacy at all stages of the patient journey.
Assess patients' social and behavioral needs and provide community resources and when necessary
Screen and assess patients for financial assistance and facilitate application for additional resources: LIS assistance for medication, medicaid, manufacture medical assistance
Screen and assess patients for isolation needs and help establish community/connection outside of medical needs
Recognize mistreatment (abuse / neglect) of patients of all ages, and understand reporting responsibilities of staff who witness abuse / neglect
Function as the behavioral health and community resource expert to care teams and actively participate and present in problem solving present during daily huddles and week interdisciplinary team meetings
Meet with care teams to collaborate and generate creative solutions to patient issues, and spearhead intervention in situations with complex psychosocial dynamics.
Accurate and timely documentation of patient encounters and counseling sessions in Oak Street's electronic medical record
Other duties, as assigned
What we're looking for
Genuine passion for primary care and reaching vulnerable patients
Comfort navigating visits in patient homes
Demonstrated ability to collaborate effectively in a team setting
Comfort with supporting patients who are facing significant health, psychosocial and/or mental health issues
Excellent communication, follow-up, teamwork, and problem-solving skills
Desire to be a part of a fast-paced, innovative, quality-driven organization
Required Qualifications
Master of Social Work degree required from a school of social work accredited by the Council on Social Work Education (CSWE)
Clinical Social Worker License (or local equivalent)
Experience performing comprehensive biopsychosocial health assessments, 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
Proficiency in providing brief, structured intervention techniques (e.g., Motivational Interviewing, Behavioral Activation, Cognitive Behavioral)
Computer skills: Ability to quickly navigate and use multiple computer programs to include, but not limited to: Gmail, MS Word or Google Docs, Excel or Google Sheets, etc.
US work authorization
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 relentlessly determined
Why Oak Street Health?
Oak Street Health is on a mission to Rebuild healthcare as it should be'', providing personalized primary care for older adults on Medicare, with the goal of keeping patients healthy and living life to the fullest. Our innovative care model is centered right in our patient's communities, and focused on the quality of care over volume of services. We're an organization on the move! With over 150 locations and an ambitious growth trajectory, Oak Street Health is attracting and cultivating team members who embody Oaky" values and passion for our mission.
Oak Street Health Benefits
Mission-focused career impacting change and measurably improving health outcomes for Medicare patients
Paid vacation, sick time, and investment/retirement 401K match options
Health insurance, vision, and dental benefits
Opportunities for leadership development and continuing education stipends
New centers and flexible work environments
Opportunities for high levels of responsibility and rapid advancement
Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply.
Anticipated Weekly Hours 40
Time Type Full time
The hours listed below are the required availability for this role. Please only apply if you can meet these schedule requirements. Shift Flexibility:
Monday: -
Tuesday: -
Wednesday: -
Thursday: -
Friday: -
Saturday: -
Sunday: -
Weekend Shift Frequency:
Language Pay Range The typical pay range for this role is:
$54,095.00 - $116,760.00
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:
Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan .
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.
For more information, visit
We anticipate the application window for this opening will close on: 07/31/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Job Tags
Hourly pay, Full time, Temporary work, Local area, Work from home, Flexible hours, Shift work, Weekend work, Sunday, Saturday,