As one of the nation’s leading pediatric health care systems, Nemours is committed to providing all children with their best chance to grow up healthy. We offer integrated, family-centered care to more than 300,000 children each year in our pediatric hospitals, specialty clinics and primary care practices in Delaware, Florida, Maryland, New Jersey and Pennsylvania. Nemours strives to ensure a healthier tomorrow for all children – even those who may never enter our doors – through our world-changing research, education and advocacy efforts. At Nemours, our Associates help us deliver on the promise we make to every family we have the privilege of serving: to treat their child as if they were our own.
The Part timeCare Coordinator - LCSW works within the context of a primary care medical home, from a team approach, and in continuous partnership with families and physicians 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 Primary Care setting by utilizing critical thinking skills and social working 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 promotes timely access to appropriate care, increasing the utilization of preventative care and healthy behaviors to improve the health of the population at risk.
Assist with or promote the identification of patients in the practice with special health care needs; add them to the registry and use the registry to plan and monitor care. Monitors chronic/preventive patient registries/lists.
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.
Case management coordination of services such as, transportation, referrals, post-hospitalization discharge; Makes follow up communication to patients/families on matters such as confirmation of delivery of equipment, emergency room visits, hospitalization, identified overdue labs/images, no show appointments, etc. in coordination with office clinical staff.
Serve as contact point, advocate and informational resource for family and community partners/payors.
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 with/for the patient/family.
Arranges for supplies and equipment. Assists with getting insurance coverage for patients without insurance.
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, 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.
Facilitates the NCQA process at the office working in close collaboration with the Medical Home liaison. Promotes/documents Quality Improvement Cycles. Responsible for generating required data.
Provide behavioral health visits as needed.
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. 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 workshops/training for teams and patients.
Must be a Licensed Clinical Social Worker
3-5 years experience required
Healthcare setting preferred
Our dedication to professionals who are dedicated to children frequently earns Nemours a spot on the list of top workplaces in the communities we serve. Our Associates enjoy comprehensive benefits, including our unique “Bridge to a Healthy Future” pediatric health plan, an integrated wellness program, opportunities for professional growth, and much more. As an equal opportunity employer, Nemours focuses on the best-qualified applicants for our openings.
Nemours is a pediatric health system of hospitals and specialty clinics serving children and families throughout the Delaware Valley and Florida. Our dedicated professionals integrate medical care, research, health education, and prevention to help improve the lives of children every day.