Care Coordination Social Worker

About the role

The Social Work Care Coordinator provides enterprise-wide care coordination services to pediatric patients with chronic conditions and medical complexity. Utilizing critical thinking skills and social work expertise, the coordinator optimizes patient outcomes among designated populations by addressing psychosocial and behavioral health needs to promote health and well-being. This role partners with patients, families, community resources, and the medical team to ensure timely access to appropriate services and supports, increasing the utilization of preventive care and healthy behaviors.

Responsibilities

• 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.
• 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.
• Identify patient and family needs, unmet needs, strengths, and assets.
• Assess biopsychosocial needs of at-risk patients (e.g., single parents, substance abuse, complex medical patients).
• Build care relationships among family and team; support the primary care-giving role of the family.
• Monitor patient care plans with family, youth, and team (e.g., emergency plan, medical summary, and action plan).
• Carry out care plans, evaluate effectiveness, monitor in a timely way, and effect changes as needed; use age-appropriate transition timetables for interventions.
• Contact identified patients for preventive services and/or pre-visit forms.
• 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.
• Coordinate inter-organizationally among family, the medical home, and involved agencies.
• Identify community resources and track select community and specialty referrals.
• Collaborate with providers to support 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 partnering with the care team to test and sustain changes.
• Facilitate referral to behavioral health visits as needed.
• Coordinate with integrated psychology providers in the primary care practice.
• Work as part of an interdisciplinary team of physicians, nursing, psychologists, and patients/families.
• Provide intervention and referral to community-based therapy or supportive resources for parents who screen positive for postpartum depression and/or anxiety.

Requirements

• Social Work license required.
• Master of Social Work (MSW) required.
• Experience with pediatric populations preferred.

About Us

Nemours Children's Health is an internationally recognized pediatric health system serving more than 1.7 million patient encounters each year. We deliver care across six states through two freestanding children’s hospitals — Nemours Children's Hospital, Delaware and Nemours Children's Hospital, Florida — along with a network of more than 80 primary, urgent, and specialty care practices and over 40 hospital partnerships. Backed by the Nemours Foundation and Alfred I. duPont Trust, our $1.7B nonprofit system is dedicated to improving children's health through clinical care, research, education, advocacy, and prevention. Our Whole Child Health approach focuses equally on prevention and treatment, partnering with communities to help every child thrive. Inclusion and belonging guide our strategy and growth, ensuring culturally relevant care, reducing health disparities, and fostering an environment where every associate, patient, and family feels supported and valued.