Care Coordination Social Worker

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🐊 Florida – Remote

🐊 Florida – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Center for Health Care Strategies

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 1998

🏥 Healthcare

💼 Consulting

⚕️ Healthcare Insurance

Healthcare • Consulting • Healthcare Insurance

Center for Health Care Strategies is a U. S. -based organization dedicated to improving the healthcare system to achieve better and more equitable outcomes, particularly for those served by Medicaid. The center focuses on issues like complex health and social needs, mental health, substance use, and aging and disability. It emphasizes cross-sector partnerships, community engagement, and health equity to transform the delivery system and promote value-based payments. The organization also supports leadership and capacity building efforts to drive system reform, including integrating Medicare and Medicaid services and advocating for trauma-informed care and primary care innovation.

📋 Description

• 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 • Help families navigate complex systems and address social, emotional, and psychosocial barriers to care • Build care relationships among families and care teams and support the primary caregiving role of families • Monitor patient care plans with families, youth, and care teams; carry out plans, evaluate effectiveness, and make changes as needed • Contact identified patients for preventive services and pre-visit forms • Coordinate access to psychosocial and practical supports, including transportation assistance, community referrals, and post-hospitalization transition resources • Provide timely follow-up outreach regarding care transitions and unmet needs • Coordinate among families, medical homes, and involved agencies • Identify community resources and track selected community and specialty referrals • Collaborate with providers on social work workflows, including social-needs screening, referral/resource linkage, care-plan integration, and follow-up • Document quality-improvement cycles by tracking outcomes, identifying barriers and opportunities, and partnering with the care team to sustain improvements • Facilitate behavioral-health referrals and coordinate with integrated psychology providers • Work with an interdisciplinary team of physicians, nursing, psychologists, and patients/families • Provide intervention and referrals to community-based therapy or supportive resources for parents screening positive for postpartum depression and/or anxiety

🎯 Requirements

• Social Work license required • MSW required • Experience with pediatric populations preferred