Population Health Social Worker

York, PA | Professional | Tracking Code: 73981

Job Description:

Under general supervision, collaborates with all members of the care team including the primary care practice to plan and implement optimal and efficient care plans for medically and psychosocially complex patients. This includes direct provision and/or assistance in the provision of psychosocial and overall mental health services for designated patients and their families in the primary care setting.Employs a range of time limited, focused, clinical interventions such as individual, group or family counseling. Provides caregiver/family counseling and/or support to promote family cohesiveness to provide care to the patient and prepare families for end of life. Advocates on behalf of patients and families to gain access to services and resources. Refers patients to other providers as necessary.Utilizes evidenced based practice and national standards to optimize the mental health of the high-risk medical and psychiatric population and to maintain these patients in the community, avoiding hospitalization when appropriate. Consults on a weekly basis with Psychiatry to review patients with complex mental health issues.This position requires a broad-based knowledge of mental health conditions, psychosocial issues and chronic diseases which impact health. Experience should include crisis management and brief supportive and transitional counseling and coaching. Knowledge of the spectrum of health care services across the continuum, available community resources, and insurance benefit design and reimbursement methods are important components of the role.


Duties and Responsibilities


  1. Utilize Motivational Interviewing techniques as a patient-centered approach to activate patients in self-management related to social determinants of health.
  2. Maintain a caseload of patients according to department policies.
  3. Meet patients in their home, primary care office, and other locations as identified.
  4. Identify patients in program for Complex Case Management/Chronic Disease Management
  5. Develop and implement care plans to maximize healthcare outcomes and facilitate wellness with periodic review and update according to department protocols.
  6. Perform medication review and teach-back to ensure patient understanding and ability to adhere to medical regimen.
  7. Collaborate with Care Managers, PCPs, Specialists, and Hospitalists to effectively implement a patient-centered care plan.
  8. Perform patient outreach according to established protocols and document in electronic medical record.
  9. Identify, execute, and track needed referrals to care and community resources
  10. Provide resource management to improve care, patient experience and reduce unnecessary cost and utilization: right care, right place, right time.
  11. Assist patient in advanced care planning to complete Advanced Directives.
  12. Documents patients’ assessments, care plans, goals and interventions in electronic medical management system according to NCQA standards.




  • Notes:
    • Other combinations of formal education, training and experience may be considered.


  • Minimum Experience:
    • 3-5 years


  • Minimum Education:
    • Bachelor's Degree


  • Preferred Education:
    • Master’s Degree


  • Preferred Field Of Expertise:
    • Social Work


  • Preferred Certification:
    • Registration: LSW or LCSW


  • Skills:
    • Excellent interpersonal/communications skills; basic computer skills
    • Able to maintain confidentiality; Able to act in a professional manner; Maintains job competency
    • all responsibilities, duties and skills required of personnel so classified.

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James Kane
James Kane
Sr. Talent Acquisition Consultant
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Why WellSpan Health?

WellSpan Health is an integrated health system that serves the communities of central Pennsylvania and northern Maryland. The organization comprises a multispecialty medical group of more than 1,600 physicians and advanced practice providers, a regional behavioral health organization, a home care organization, eight respected hospitals, more than 20,000 employees and 200 patient care locations. WellSpan is a charitable, mission-driven organization committed to exceptional care for all, lifelong wellness and healthy communities. We are committed to transforming the health of the communities we serve and to educating the next generation of clinicians, staff and leaders.

Employment Benefits

  • Sign-on incentives for new employees (click here for details)
  • Medical, dental and vision insurance
  • Life and accidental death insurance
  • Supplemental life insurance
  • Retirement savings plan
  • Paid time off (PTO)
  • PTO bridging
  • Short-term disability
  • Educational assistance
  • Forgivable loan
  • Flexible spending
  • Credit union
  • Employee recreational activities
  • Childcare
  • Complimentary medicine discounts

Diversity & Inclusion

Welcome. Respect. Value.

Wellspan Health believes that diversity includes all the human characteristics that make each of us similar as well as different. We strive to make every person feel welcomed, respected, and valued while creating a safe and inclusive environment where we all have the individual freedom to express our uniqueness in a respectful manner.

WellSpan Health is an Equal Opportunity Employer. It is the policy and intention of the System to maintain consistent and equal treatment toward applicants and employees of all job classifications without regard to age, sex, race, color, religion, sexual orientation, gender identity, transgender status, national origin, ancestry, veteran status, disability, or any other legally protected characteristic. WellSpan Health does, however, have a tobacco-free/nicotine-free hiring policy.

Quality of Life

Founded in 1741, the city of York is considered by many as the first capital of the United States. The Articles of Confederation were signed by the Second Continental Congress here in 1777. Its beautifully restored historic district is an architectural treasure. While York retains its farming and manufacturing heritage, at its heart York is a thriving cultural community that has attracted creative talent and innovative entrepreneurial investors from across the nation.

Life in York County offers affordable housing, options for higher education, a thriving arts and cultural community, historical attractions, parks and recreational resources, semi-professional baseball team, fine dining and more — within an easy drive of major East Coast cities.

York County residents can find local employment in healthcare, manufacturing, technology, agricultural and service sectors. (Patient population: 445,000)