Population Health Social Worker

The Ohio State University

1d•Onsite

About The Position

The Population Health Social Worker serves as a behavioral health and social work expert on the Population Health Care Management Team within a Value-Based Care model. This role supports highly complex patients by identifying and addressing behavioral health, substance use, and non-medical social needs and coordinating services to promote patient-centered, comprehensive care. The Population Health Social Worker provides psychosocial assessments, trauma-informed care, harm reduction support, and care coordination while helping patients and families navigate challenges related to medical diagnoses and other complex circumstances. The Social Worker facilitates access to behavioral health, substance use, medical, and social support services, including mental health agencies, providers and facilities, rehabilitation, long-term care placement, hospice, and other community-based resources. The Population Health Social Worker develops and maintains strong relationships with OSU behavioral health resources, health care providers, interdisciplinary care teams, and community partners to facilitate access to needed services and address barriers to care. The role serves as a trusted resource and subject matter expert, providing guidance related to behavioral health and social work needs and supporting the implementation of appropriate interventions and services for patients and families. Through collaboration across the health care and community systems, the Population Health Social Worker helps improve care coordination, address social and behavioral health barriers, support positive patient outcomes, and reduce avoidable acute care utilization. The ideal candidate will demonstrate strong clinical and interpersonal skills, a commitment to patient advocacy, and the ability to build collaborative relationships across complex health care and community environments.

Requirements

Master of Social Work from an accredited Graduate School of Social Work required
State of Ohio Social Work licensure (LSW or LISW) required
1 year of relevant experience required

Nice To Haves

Experience in a physician’s office or other primary health care setting desirable
2-4 years of relevant experience preferred

Responsibilities

Serves as a behavioral health and social work expert on the Population Health Care Management Team within a Value-Based Care model.
Supports highly complex patients by identifying and addressing behavioral health, substance use, and non-medical social needs.
Coordinates services to promote patient-centered, comprehensive care.
Provides psychosocial assessments, trauma-informed care, harm reduction support, and care coordination.
Helps patients and families navigate challenges related to medical diagnoses and other complex circumstances.
Facilitates access to behavioral health, substance use, medical, and social support services, including mental health agencies, providers and facilities, rehabilitation, long-term care placement, hospice, and other community-based resources.
Develops and maintains strong relationships with OSU behavioral health resources, health care providers, interdisciplinary care teams, and community partners.
Serves as a trusted resource and subject matter expert, providing guidance related to behavioral health and social work needs.
Supports the implementation of appropriate interventions and services for patients and families.
Improves care coordination, addresses social and behavioral health barriers, supports positive patient outcomes, and reduces avoidable acute care utilization through collaboration across health care and community systems.