Care Management Coordinator

Northwell•Village of Sleepy Hollow, NY

About The Position

Coordinates and delivers evidence-based interventions to children 0-5 years old, and their families, who present with social needs and/or developmental concerns.

Requirements

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.

Responsibilities

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 escalate 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.