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.

Job Responsibility

• 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.    

Job Qualification

• 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.

*Additional Salary Detail 

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).