Care Management Coordinator - MSW

Responsibilities

• Implement and sustain the evidence-based HealthySteps model to support families of children ages 0-5 with development, learning, 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, respond to and track call requests within the designated response time.
• Provide appropriate referrals to families for support with individualized needs.
• Document all clinical activities and care coordination in the electronic health record while maintaining 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 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.
• Facilitate caregiver support groups as appropriate.
• Participate in reflective clinical supervision meetings.
• Maintain accurate records of caseload data 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.

Pay

The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget, and internal equity).