Care Management Coordinator - MSW

About the role

Coordinates and delivers evidence-based interventions to children 0-5 years old, and their families, who present with social needs and/or developmental concerns.

Responsibilities

• Implement and sustain the evidence-based HealthySteps model in supporting families of children ages 0-5 with development, learning and growth, and overall wellbeing, in conjunction with the pediatric primary care team.
• Joins and participates in in-person team-based well visits to reach families during primary care appointments.
• Creates and maintains up-to-date community partnership and resource directory.
• Maintains a HealthySteps family support line and responds to and track call requests within designated response time.
• Provides appropriate referrals to families for support with individualized needs.
• Appropriately documents all clinical activities and care coordination in the electronic health record with consideration to patient confidentiality.
• Attend and participate in team meetings, huddles, and patient care meetings as appropriate.
• Tracks caseload to ensure capacity to deliver HealthySteps services within the delivery model.
• Ensure when termination criteria are met and/ or escalate families requiring further support to higher levels of care through health system and community referrals, as appropriate.
• Use team-based communication strategies to close the loop on referrals and follow up for outstanding patient needs.
• May facilitate caregiver support groups as appropriate.
• Participates in reflective clinical supervision meetings.
• Maintains accurate records of caseload data as appropriate for program management, evaluation, and reporting purposes.

Qualifications

• Master’s degree in social work or related field, required.
• NYS Licensure required within 6 months of hire, if applicable.
• 1-3 years of relevant experience working with children and families, required.
• Successful completion of the HealthySteps Specialist training within 6 months of hire.