Population Health Engagement Coordinator - York - Days

  • York, PA
  • WellSpan Population Health
  • WPH Medical Management
  • Full Time - Day
  • Professional
  • Req #: 64769
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Job Description:

Is responsible for outreaching and engaging to assigned populations to support the connection to social service agencies and mitigation of social determinants of need barriers, including but not limited to: long-term care support, horizon planning, and support of discharge patients with social needs. Based on a algorithms and department protocols, is responsible for identifying candidates who have complex or ongoing needs and appropriately referring them to care management programs/resources. Provides administrative support for the centralized care management unit and works under the guidance and direction of the leadership of Population Health to provide social work support to the Customer’s population.

 

Duties and Responsibilities

  1. Assists with patient engagement and outreach, care coordination services, and navigation of the health care system.
  2. Utilizes population management data and resources to identify at risk patients and facilitate appropriate support and resources.
  3. Provides patient outreach and engagement assessment related to social determinants of health and removes barriers to success.
  4. Facilitates patient engagement with their medical home and regional care management team, assists with access to and navigation of the health care system.
  5. Appropriately documents assessments and interventions in the patient's electronic medical record.
  6. Participates in care team meetings, performance improvement and patient and customer experience initiatives.
  7. Reports issues and system barriers to efficient and effective care management.
  8. Carries a case load for patients recently discharged from a WellSpan facility with ongoing social support needs who are not assigned to a member of the Ambulatory Care Management team.
  9. Acts as social work resource within the centralized population health care management unit.
  10. Assists with onboarding of new Social Worker and Community Health Worker team members
 

Qualifications

  • Minimum Experience:
    • 3 - 5 years
  • Minimum Education:
    • Bachelor's Degree Social Work
  • Preferred Field Of Expertise:
    • Population health, case management, or social work specialty
  • Required Certification:
    • CCM obtained within 2 years of hire
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