Care Management Coordinator - MSW

Northwell Health; New York (NY); On-site; USD 65,000 - 90,000; Full time

Job summary

Northwell Health seeks a qualified professional to coordinate evidence-based HealthySteps interventions for children aged 0–5 and their families within the pediatric primary care team.

The role involves in-person well visits, developing a resource directory, maintaining a family support line, and timely referrals. Strong documentation, teamwork, and the ability to manage caseload are essential.

Qualifications

• Master’s degree in social work or related field is required.
• NYS Licensure required within 6 months of hire, if applicable.
• 1–3 years of relevant experience working with children and families is required.
• Successful completion of the HealthySteps Specialist training within 6 months of hire.

Responsibilities

• Implement and sustain the HealthySteps model with families of children ages 0–5 during pediatric primary care visits.
• Participate in in-person team-based well visits to reach families.
• Maintain an up-to-date community partnership and resource directory.
• Operate a HealthySteps family support line and respond to call requests within the designated response time.
• Provide appropriate referrals to families for individualized needs.
• Document all clinical activities and care coordination in the EHR while protecting patient confidentiality.
• Attend team meetings, huddles, and patient care meetings as appropriate.
• Track caseload to ensure capacity within the program delivery model and coordinate higher-level referrals when needed.
• Use team-based communication to close the loop on referrals and follow up on outstanding needs.
• Facilitate caregiver support groups as appropriate.
• Participate in reflective clinical supervision meetings.
• Maintain accurate caseload data for program management, evaluation, and reporting purposes.

Education

Master’s degree in social work or related field

Job description

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.

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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 escape 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).