Career Center

The Social Work care coordinator will work within the context of the Diagnostic Referral Department, and other specialty departments, as needed to coordinate care. The Social Worker will assist patients and families in identifying social, psychological, behavioral and environmental needs that may impact the ability to maintain healthy behaviors and disease management. The SW will assist in connecting patients and families with available, appropriate resources and services through the provision of a full spectrum of transition planning and social work services. The SW will identify and monitor pediatric patient needs in collaboration with the clinical team around care coordination. She/he will collaborate with the patient/family, physicians, staff and other health care professionals across the continuum to provide care coordination and patient services to achieve positive clinical, operational and financial outcomes.

The care coordinator is accountable for adherence to policies and procedures of Nemours Children's Health, Delaware Valley and other affiliated hospitals to which Nemours-delegated patients are admitted/seek care.

The care coordinator is expected to maintain all state and federal clearances for DE.

Assist with the identification of patients within the Diagnostic Referral Department who require care coordination assistance as related to chronic care needs, needs related to Social Determinants of Health (SDOH), and coordination of services.

Identifies problems or gaps in community resources that impact outcomes and takes leadership in efforts to effect changes. Coaches patients and their families on red flags, triggers, medication management, and follow-up appointments.

Gathers and assesses information regarding the patient's physical needs, mental status, family support system, financial resources, and available community and governmental resources to support plan of care.

Provides psychosocial support through individual and/or family counseling. Continuously reviews service area for group/family support needs and opportunities and refers to appropriate resources.

Manages assigned case load in an efficient and effective manner utilizing time management skills.

Initiate family contacts; create ongoing processes for families to determine and request the level of care-coordination support they desire for their child/youth or family member at any given point in time.

Works cooperatively with families, patients, other members of the treatment team, social service agencies, community resources, and public agencies. Collaborates with the family and team to arrange for health care needs. Acts as a liaison for agencies and families with identified healthcare needs.

Facilitates coordination of services such as, transportation, referrals, and compliance. Assists families and patients through the healthcare system by acting as patient advocate and navigator connecting patients to relevant community resources with the goal of enhancing patient health and wellbeing.

Serve as point of contact, advocate and informational resource for family, patient, care team, school systems and their school nurses, community resources, and state agencies. Facilitates meetings/calls between patient /family, care team, payors, and outside agencies as needed.

Participates in data collection, health outcomes reporting, clinical audits, and program evaluation. Assists with the identification of areas for improvement within their practice.

Identify patients at risk for poor transitions, high Emergency Department utilization and/or readmission to hospital. Will complete a comprehensive transition assessment and plan for on-going touchpoints for these patients. Will communicate needs and plan to providers, care team, outpatient care coordinators and, care managers, if referral is indicated.

Requirements-

Master's Degree Required

Case Management Certification preferred: CCM, ACM-RN

Minimum of 1 year relevant experience