Care Coordinator-School-Based Health Centers (10-month ...

Job DescriptionNemours is seeking a Care-Coordinator (10 months) to join the Nemours Children's Health team. The School Based Health Center (SBHC) Social Work Care Coordinator works within the context of our SBHC, from a team approach, and in continuous partnership with families and providers to promote: timely access to needed care, comprehension and continuity of care, and the enhancement of child and family well being. Provides Care Coordination in the SBHC setting by utilizing critical thinking skills and social worker expertise in order to optimize patient outcomes amongst designated populations within the practice. Works with patients and families to ensure both behavioral and psychosocial needs are met in order to promote health and well-being. Addresses gaps in care and Social Determinant needs and promotes timely access to appropriate careresources, increasing the utilization of preventative care and healthy behaviors to improve the health and well being of the population at risk. Essential FunctionsAssist with or promote the identification of patients in the practice with special health care, Behavioral Health, and chronic illness needs. Will act as a liaison within the primary care practice team. Monitors and utilizes registries to plan and monitor care including but not limited to chronicpreventative patient registrieslists. Initiate family contacts; create ongoing processes for families to determine and request the level of care-coordination support they desire for their childyouth or family member at any given point in time. May facilitate or assist with Family Advisory Committee.Identify 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. Promotes teams and actively participates in daily huddles. Organizes workshopstraining for teams and patients.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 familyyouthteam (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 andor pre-visit forms.Case management coordination of services such as, transportation, referrals, post-hospitalization discharge; Makes follow up communication to patientsfamilies on matters such as confirmation of delivery of equipment, emergency room visits, hospitalization, identified overdue labsimages, no show appointments, etc. in coordination with office clinical staff.Serve as contact point, advocate and informational resource for family and community partnerspayors. Referrals to child protective services and appropriate agencies for domestic violence. Completes forms such as DFS, FMLA, SSI, etc. and writes letters for housing, nursing care, medical necessity, etc.; Research, find and link resources, services, and supports withfor the patientfamily. Arranges for supplies and equipment. Make referrals to Nemours Financial Assistance Department and support procurement of patient health insurance, as neededCoordinate 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, i.e., WIC, food stamps, DME providers, advocacy groups, schools, financial assistance, counseling, anger management classes, special needs camps or inner-city camps. Refer patients to early intervention and public health nurses and help office staff and parents navigate through the school system and help with IEPs.Collaborates with the practice on the NCQA process at the office working in close collaboration with the Medical Home liaison. Promotesdocuments Quality Improvement Cycles. Facilitate referral to behavioral health visits as needed.LMSW or LCSW RequiredAbout UsNemours Children's Health is an internationally recognized children's health system. With more than 1.7 million patient encounters annually, we provide medical care in five states through two freestanding state-of-the-art children's hospitals - Nemours Children's Hospital, Delaware and Nemours Children's Hospital, Florida. Our pediatric network includes 80 primary-urgent-and specialty care practices and more than 40 hospitalists serving 19 affiliated hospitals. We generate annual revenues of more than $1.7 billion derived from patient services, contributions from the Alfred I. DuPont Trust, as well as other income.As one of the nation's premier pediatric health systems, we're on a journey to discover better ways of approaching children's health. Putting as much focus on prevention as cures and working hand in hand with the community to make every child's world a place to thrive. It's a journey that extends beyond our nationally recognized clinical treatment to an entire integrated spectrum of research, advocacy, education, and prevention, leading to the healthiest generations of children ever.Equity, diversity, and inclusion guide our growth and strategy. We are looking for individuals who are passionate about, and committed to, leading efforts to provide culturally relevant care, reducing health disparities, and helping build a diverse and inclusive environment. All of our associates are expected to ensure that these philosophies are embedded in their day-to-day work with colleagues, patients and families. To learn more about Nemours Children's and how we go well beyond medicine, visit us at

Created: 2025-02-22