Population Health Social Worker

About the role

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.

Responsibilities

• Provide psychosocial assessments, trauma-informed care, harm reduction support, and care coordination.
• Help patients and families navigate challenges related to medical diagnoses and other complex circumstances.
• Facilitate 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.
• Develop and maintain 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.
• Serve 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.
• Collaborate across health care and community systems to improve care coordination, address social and behavioral health barriers, support positive patient outcomes, and reduce avoidable acute care utilization.

Qualifications

• Master of Social Work from an accredited Graduate School of Social Work (required)
• State of Ohio Social Work licensure (LSW or LISW) (required)
• Experience in a physician’s office or other primary health care setting (desirable)
• Minimum 1 year of relevant experience (required); 2‑4 years preferred

Skills

• Strong clinical and interpersonal skills
• Commitment to patient advocacy
• Ability to build collaborative relationships across complex health care and community environments