Care Coordination Social Worker

The Social Work Care Coordinator provides enterprise-wide care coordination services to pediatric patients with chronic conditions and medical complexity by utilizing critical thinking skills and social work expertise to optimize patient outcomes among designated populations. Working in partnership with patients, families, community resources, and the medical team, the coordinator helps ensure that psychosocial and behavioral health needs are identified and addressed to promote health and well-being. The coordinator addresses gaps in care and promotes timely access to appropriate services and supports, increasing the utilization of preventive care and healthy behaviors to improve the health of at-risk populations.

The Social Work Care Coordinator will coordinate team-based care to support and educate patients and families through effective partnerships with interdisciplinary care team members, integrated behavioral health providers, and community-based agencies. This role helps families navigate resources and services that reduce barriers to care and supports continuity across settings.

Responsibilities:

1. Conduct comprehensive screening and assessment of health-related social needs and behavioral health factors affecting pediatric patients and families. Provide short-term intervention, education, and support to address identified needs and promote stability and engagement in care.

    

2. Facilitate connections to internal services and community-based resources, including behavioral health, social services, and community supports. Support families in navigating complex systems to address social, emotional, and psychosocial barriers to care.

3. Identify patient and family needs and unmet needs, strengths and assets.  Assess biopsychosocial needs of at-risk patients, i.e., single parents, substance abuse, complex medical patients, etc. 

4. Build care relationships among family and team; support the primary care-giving role of the family.

5. As a member of the care team, monitor patient care plans with family/youth/team (emergency plan, medical summary and action plan as appropriate).  Carry out care plans, evaluate effectiveness, monitor in a timely way and effect changes as needed; use age appropriate transition timetables for interventions within care plans.  Contacts identified patients for preventative services and/or pre-visit forms.

6. Coordinate and facilitate access to psychosocial and practical supports (e.g., transportation assistance, community referrals, and post-hospitalization transition resources). Provide timely follow-up outreach to patients/families regarding care transitions and unmet needs. 

7. Coordinate inter-organizationally among family, the medical home, and involved agencies.  Identifies community resources and tracks select community and specialty referrals.  Connect to and understand community resources

8. Collaborate with the providers to support activities related to social work workflows (e.g., social needs screening, referral/resource linkage, care plan integration, and follow-up). Contribute to and document quality improvement cycles by tracking outcomes, identifying barriers and opportunities for improvement, and partnering with the care team to test and sustain changes that improve patient and family experience and continuity of care

10. Facilitate referral to behavioral health visits as needed. Coordinate with integrated psychology providers in the primary care practice. Work as part of the inter-disciplinary team of physicians, nursing, psychologist, and patient/family. Provide intervention and referral to community-based therapy or supportive resources for parents who screen positive for postpartum depression and/or anxiety.

Qualifications:

• Social Work license required 

• MSW required 

• Experience with pediatric populations preferred