Care Management Coordinator - MSW

Job Description

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.
• Join and participate in in‑person team‑based well visits to reach families during primary care appointments.
• Create and maintain an up‑to‑date community partnership and resource directory.
• Maintain a HealthySteps family support line and respond to and track call requests within designated response time.
• Provide appropriate referrals to families for support with individualized needs.
• Appropriately document 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.
• Track 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.
• Participate in reflective clinical supervision meetings.
• Maintain 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.