Care Coordination Social Worker

This is a fully remote position, open to applicants in Florida.

📋 Description

• Perform thorough screenings and evaluations of health-related social needs and behavioral health elements impacting pediatric patients and their families.

• Offer short-term intervention, education, and support to meet identified needs, fostering stability and engagement in care.

• Facilitate access to internal services and community-based resources, including behavioral health, social services, and community support systems.

• Assist families in navigating complex systems and addressing social, emotional, and psychosocial obstacles to care.

• Cultivate care relationships between families and care teams while supporting the primary caregiving role of families.

• Oversee patient care plans in collaboration with families, youth, and care teams; implement plans, assess effectiveness, and adjust as necessary.

• Reach out to designated patients for preventive services and pre-visit documentation.

• Coordinate access to psychosocial and practical supports, including transportation assistance, community referrals, and resources for post-hospitalization transitions.

• Provide timely follow-up outreach concerning care transitions and unmet needs.

• Coordinate efforts among families, medical homes, and involved agencies.

• Identify community resources and monitor selected community and specialty referrals.

• Collaborate with providers on social work processes, including social-needs screenings, referral/resource connections, care-plan integration, and follow-up.

• Document quality improvement efforts 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.

• Collaborate with an interdisciplinary team of physicians, nursing staff, psychologists, and patients/families.

• Provide interventions and referrals to community-based therapy or supportive resources for parents identified as screening positive for postpartum depression and/or anxiety.

⛳️ Requirements

• A valid Social Work license is required.

• A Master's in Social Work (MSW) is mandatory.

• Experience with pediatric populations is preferred.

🏝️ Benefits

• Competitive salary and comprehensive benefits package.

• Opportunities for professional development and continuing education.

• Supportive work environment with a focus on teamwork and collaboration.