Care Coordination Social Worker

Nemours in; Orlando (FL); On-site; USD 65,000 - 90,000; Full time

Job summary

Nemours Children's Health in Orlando is seeking a Care Coordination Social Worker to support enterprise-wide care coordination for pediatric patients with chronic conditions. The role partners with families, the medical team, and community resources to identify psychosocial needs and promote timely access to services.

Key duties include screening for social needs, coordinating access to behavioral health and social supports, and collaborating with interdisciplinary teams to implement care plans.

Qualifications

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

Responsibilities

• 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. Support families in navigating complex systems to address social, emotional, and psychosocial barriers to care.
• Identif <b>y</b> patient and family needs and unmet needs, strengths and assets. Assess biopsychosocial needs of at-risk patients, i.e., single parents, substance abuse, complex medical patients, etc.
• Build care relationships among family and team; support the primary care-giving role of the family.
• As a member of the care team, monitor patient care plans with family/youth/team (emergency plan, medical summary and action plan as appropriate). Carry out care plans, evaluate effectiveness, monitor in a timely way and effect changes as needed; use age appropriate transition timetables for interventions within care plans. Contacts identified patients for preventative services and/or pre-visit forms.
• Coordinate and facilitate access to psychosocial and practical supports (e.g., transportation assistance, community referrals, and post-hospitalization transition resources). Provide timely follow-up outreach to patients/families regarding care transitions and unmet needs.
• Coordinate inter-organizationally among family, the medical home, and involved agencies. Identifies community resources and tracks select community and specialty referrals. Connect to and understand community resources
• Collaborate with the providers to support activities related to social work workflows (e.g., social needs screening, referral/resource linkage, care plan integration, and follow-up). Contribute to and document quality improvement cycles by tracking outcomes, identifying barriers and opportunities for improvement, and partnering with the care team to test and sustain changes that improve patient and family experience and continuity of care
• Facilitate referral to behavioral health visits as needed. Coordinate with integrated psychology providers in the primary care practice. Work as part of the inter-disciplinary team of physicians, nursing, psychologist, and patient/family. Provide intervention and referral to community-based therapy or supportive resources for parents who screen positive for postpartum depression and/or anxiety.

Education

MSW

Social Work license

Job description

Care Coordination Social Worker (Finance)

Care Coordination Social Worker (Finance)

The Social Work Care Coordinator provides enterprise-wide care coordination services to pediatric patients with chronic conditions and medical complexity by utilizing critical thinking skills and social work expertise to optimize patient outcomes among designated populations. Working in partnership with patients, families, community resources, and the medical team, the coordinator helps ensure that psychosocial and behavioral health needs are identified and addressed to promote health and well-being. The coordinator addresses gaps in care and promotes timely access to appropriate services and supports, increasing the utilization of preventive care and healthy behaviors to improve the health of at-risk populations.

The Social Work Care Coordinator will coordinate team-based care to support and educate patients and families through effective partnerships with interdisciplinary care team members, integrated behavioral health providers, and community-based agencies. This role helps families navigate resources and services that reduce barriers to care and supports continuity across settings.

Responsibilities

• 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. Support families in navigating complex systems to address social, emotional, and psychosocial barriers to care.
• Identif y patient and family needs and unmet needs, strengths and assets. Assess biopsychosocial needs of at-risk patients, i.e., single parents, substance abuse, complex medical patients, etc.
• Build care relationships among family and team; support the primary care-giving role of the family.
• As a member of the care team, monitor patient care plans with family/youth/team (emergency plan, medical summary and action plan as appropriate). Carry out care plans, evaluate effectiveness, monitor in a timely way and effect changes as needed; use age appropriate transition timetables for interventions within care plans. Contacts identified patients for preventative services and/or pre-visit forms.
• Coordinate and facilitate access to psychosocial and practical supports (e.g., transportation assistance, community referrals, and post-hospitalization transition resources). Provide timely follow-up outreach to patients/families regarding care transitions and unmet needs.
• Coordinate inter-organizationally among family, the medical home, and involved agencies. Identifies community resources and tracks select community and specialty referrals. Connect to and understand community resources
• Collaborate with the providers to support activities related to social work workflows (e.g., social needs screening, referral/resource linkage, care plan integration, and follow-up). Contribute to and document quality improvement cycles by tracking outcomes, identifying barriers and opportunities for improvement, and partnering with the care team to test and sustain changes that improve patient and family experience and continuity of care
• Facilitate referral to behavioral health visits as needed. Coordinate with integrated psychology providers in the primary care practice. Work as part of the inter-disciplinary team of physicians, nursing, psychologist, and patient/family. Provide intervention and referral to community-based therapy or supportive resources for parents who screen positive for postpartum depression and/or anxiety.

Qualifications

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

About Us

Nemours Children's Health is an internationally recognized pediatric health system serving more than 1.7 million patient encounters each year. We deliver care across six states through two freestanding children's hospitals - Nemours Children's Hospital, Delaware and Nemours Children's Hospital, Florida - along with a network of more than 80 primary, urgent, and specialty care practices and more than 40 hospital partnerships.

Backed by the Nemours Foundation and Alfred I. duPont Trust, our $1.7B nonprofit system is dedicated to improving children's health through clinical care, research, education, advocacy, and prevention. Our Whole Child Health approach focuses equally on prevention and treatment, partnering with communities to help every child thrive.

Inclusion and belonging guide our strategy and growth. We are committed to culturally relevant care, reducing health disparities, and fostering an environment where every associate, patient, and family feels supported and valued.

Learn more at Nemours.org .