Social Services Coordinator

Social Work Services

Plans, organizes and implements social work services for patients and families. Provides social work consultation to staff, patient counseling and direct social work services to assigned patients in accordance with the agency's standards and policies.

Essential Functions:

• Conducts comprehensive biopsychosocial and social needs assessments, identifying social, emotional, financial, behavioral, and environmental factors that impact health outcomes and care plan adherence.
• Utilizes motivational interviewing and other engagement strategies to build rapport and support patient-identified goals of care.
• Provides longitudinal care management for patients with high-risk, high-utilization, or complex needs while collaborating with RN Care Managers, Health Coaches, Community Health Workers, pharmacy teams, behavioral health, and primary care providers to ensure coordinated interventions and shared accountability.
• Connects patients to appropriate internal and external resources, including financial assistance, home- and community-based services, benefits programs, transportation, food supports, caregiver services, housing solutions, and behavioral health services.
• Ensures referrals are tracked, followed up, and closed with documented outcomes.
• Assists in the orientation of new staff or continuing education of existing staff as requested.
• Delivers supportive intervention and problem-solving related to adjustment to illness, caregiver strain, grief, behavior change, and medical decision-making, while assisting patients and families in understanding and engaging in treatment plans, care expectations, and available support systems.
• Assists with complex issues such as guardianship, advance directives, disability applications, and long-term care planning, and collaborates with hospital programs and community agencies involved in the patient's care.
• Participates in care transition planning to ensure safe and coordinated movement between hospital, post-acute, and home settings.
• Maintains accurate, timely, and clinically appropriate documentation in the electronic health record and consistently meets assigned productivity, outreach, engagement, and outcome expectations.
• Participates in interdisciplinary case reviews, huddles, and care team meetings, and actively seeks consultation or direction from management personnel as appropriate.
• Participates in staff development and in-service programs, as requested, and promotes a positive corporate image.

Common Expectations:

• Adheres to all safety regulations, organizational policies, and quality standards; identifies opportunities to reduce errors, supports infection control practices, and participates in safety education and root-cause analysis as required.
• Participates in ongoing education, in-service training, and professional growth activities; provides outstanding service to patients and colleagues; and contributes to teamwork, innovation, and fiscal responsibility.
• Completes timely and appropriate documentation in the electronic medical record, ensures care plans and interventions are captured appropriately, and attends required meetings and departmental activities.

Minimum Education:

• Bachelors Degree In Health and Human Services Field. Required
• Masters Degree Preferred

Work Experience:

• Less than 1 year Relevant experience. Required
• Less than 1 year Experience in healthcare Preferred
• Less than 1 year Experience in Community Health. Preferred

Knowledge, Skills, and Abilities:

• Excellent interpersonal/communications skills and basic computer skills.
• Able to maintain confidentiality.
• Able to act in a professional manner.
• Maintains job competency.

Benefits Offered:

• Comprehensive health benefits
• Retirement savings plan
• Paid time off (PTO)
• Education assistance
• Financial education and support, including Daily Pay
• Expanded Paid Parental Leave

Well Span Health's vision is to reimagine healthcare through the delivery of comprehensive, equitable health and wellness solutions throughout our continuum of care. As an integrated delivery system focused on leading in value-based care, we encompass more than 2,300 employed providers, 250 locations, nine award-winning hospitals, home care and a behavioral health organization serving central Pennsylvania and northern Maryland. Our high-performing Medicare Accountable Care Organization (ACO) is the region's largest and one of the best in the nation.

With a team 23,000 strong, Well Span experts provide a range of services, from wellness…