Clinical Care Coordinator - Sala Care Coordination Program MSW & LCSW required

NYU Langone Health•New York, NY

3d•$70,482 - $121,581

About The Position

The Care Coordinator leads the psychosocial components of follow up care, including post-discharge assessments, identification of barriers to care, short-term adjustment counseling, and connection to community and medical resources. Utilizing a trauma-informed, family-centered approach, the role advocates for patients and families, promotes self-management, and coordinates services over a 3-12 month period. The Care Coordinator collaborates closely with primary care, subspecialty providers and their HCH social workers, integrated behavioral health, and community partners to ensure continuity, alignment of care plans, and improved patient and family outcomes.

Requirements

Masters degree in Social Work (MSW) from an accredited school of social work
Current New York State licensure as a Licensed Clinical Social Worker (LCSW) required
Minimum of 3 years of pediatric social work experience required
Experience with medically complex children, chronic illness, hospital-to-home transitions, and family-centered care strongly preferred
Experience conducting psychosocial assessments, crisis assessment, brief counseling, and resource coordination in pediatric hospital, ambulatory, or complex care settings required
Demonstrated experience addressing social determinants of health, caregiver stress, adherence barriers, and access to community-based supports and entitlements
Experience collaborating across multidisciplinary teams, including physicians, APPs, nursing, behavioral health, case management, schools, and community agencies required
Qualified candidates must be able to effectively communicate with all levels of the organization.

Nice To Haves

experience with medically complex children
chronic illness
hospital-to-home transitions
family-centered care

Responsibilities

Facilitate clear handoff process between inpatient team, family, and Sala Care Coordination team; co-lead discharge rounds to connect with family prior to discharge
Conduct robust psychosocial assessment via telehealth within 24-72 hours post-discharge and subsequent psychosocial assessments over subsequent encounters over the following 3-12 months
Conduct psychosocial assessments to evaluate needs and challenges
Identify and connect patients to community resources tailored to their specific needs
Escalate any medical concerns to Nurse Coordinator
Assess effectiveness of plan
Help facilitate longer-term resource planning and linkage for families who require ongoing supports beyond the immediate post-discharge period
Utilize a family-centered, trauma-informed approach to assess psychosocial stressors and provide supportive counseling to children and families coping with complex illness, hospitalization, and transitions in care
Develop individualized plans to alleviate indicated stressors by mobilizing community resources that are pertinent to patient/family needs
Provide counseling and interventions concerning: impact of diagnosis, chronic/life threatening illness/treatment, end of life care, impact on education and work, abuse or neglect, parenting, financial supports, impact on family dynamics, mental health, alcohol/substance abuse; health care coverage, and home care services
Connect families to community resources/programs to alleviate psychosocial burdens related to medical, emotional, and economic stressors, including but not limited to: insurance funded home care supports for short and long term care needs, rehabilitation therapies, benefits and entitlements, home and vehicle modifications to accommodate medical needs, family support services, and educational advocacy (e.g., Early Intervention, Preschool, School-Age, and Young Adult services)
Help families and patients build self-management capacity through access to resources, education, problem-solving support, and ongoing psychosocial guidance
Reinforce family-centered care planning that empowers caregivers to manage their childs care more confidently across settings
Act as a central advocate for patients and their families, ensuring social and psychosocial needs are met
Facilitate coordination of social support services to ensure patients and families achieve self-management of care
Serve as the primary psychosocial liaison across inpatient, outpatient, and community settings to ensure family needs, preferences, and barriers are communicated to the interdisciplinary team
Partner closely with the Nurse Coordinator to translate complex medical plans into actionable, family-centered community care plans that address psychosocial, cultural, and socioeconomic factors impacting adherence
Proactively identify and communicate psychosocial risks or changes in family circumstances that may impact medical care, escalating concerns to the Program Manager and care team as appropriate
Follow-up with primary care and subspecialist team to understand updates, the current state of care, and any potential barriers impacting the patients health
Partner with the Nurse Coordinator in a shared care model from discharge through program transition, with joint responsibility for continuity, family engagement, and coordination across settings
Role reports to Assistant Director, Social Work
Performs other duties as assigned