Social Worker Care Coordinator

• Conduct member outreach to identify social needs, barriers to care, and available support systems using established screening tools and workflows.
• Complete SDOH screenings and document identified needs, including housing, food access, transportation, financial concerns, caregiver support, access to care, and other social barriers.
• Provide members with information regarding available community resources, entitlement programs, transportation services, food assistance, housing resources, and other appropriate support programs.
• Assist members with referrals to community-based organizations, governmental agencies, health plan programs, and other approved resources.
• Follow up on referrals and resource connections to determine whether members were able to access services and identify unresolved barriers.
• Assist with care coordination activities for members transitioning between inpatient, post-acute, and community settings.
• Support discharge-planning activities by gathering and organizing relevant social and administrative information and communicating identified barriers to the appropriate clinical team member.
• Assist with coordination of post-acute services, including skilled nursing facilities, rehabilitation facilities, home care, transportation, and community-based services, under established workflows and in collaboration with the appropriate clinical staff.
• Facilitate communication among members, families, hospitals, community providers, and internal care team members regarding non-clinical needs and available resources.
• Obtain and organize psychosocial, social, and administrative information for review by RN staff, licensed social workers, Medical Directors, and other appropriate clinical team members.
• Participate in interdisciplinary team meetings and rounds as appropriate to provide updates regarding social needs, resource referrals, barriers to care, and member engagement.
• Escalate complex psychosocial concerns, behavioral health concerns, safety concerns, crisis situations, and clinical needs to designated clinical professionals.
• Assist the care team in identifying barriers that may contribute to missed appointments, medication access issues, difficulty obtaining services, or challenges with adherence to the member’s established care plan.
• Assist with identification of behavioral health needs and facilitate referrals to designated behavioral health resources
• Follow up with external behavioral health vendors regarding referrals and service connection, as directed by the care team.

• Support continuity of care by maintaining communication with members and appropriate providers regarding referrals, appointments, services, and identified social needs.
• Assist with identification of placement and discharge barriers and communicate unresolved issues to the appropriate clinical or operational team member.
• Gather information for subacute rehabilitation, acute rehabilitation, and LTACH cases as requested by RN staff, licensed social workers, or Medical Directors.
• Assist with organization of information required for case preparation and interdisciplinary review.
• Communicate established determinations, referrals, and next steps to members and appropriate parties after decisions have been made by the authorized clinical or medical staff.
• Maintain accurate and timely documentation of member contacts, screenings, referrals, resource connections, follow-up activities, and escalations in the appropriate systems.
• Utilize computer software applications for documentation, data entry, tracking, reporting, and preparation of routine correspondence and documents.
• Maintain working knowledge of community resources and governmental programs relevant to the member population.
• Assist with departmental reporting, audits, quality initiatives, surveys, and other administrative activities as assigned.
• Participate in special projects, program implementation, and operational initiatives as assigned.
• Complete required training, webinars, and educational activities within established timelines.
• Demonstrate professional communication, active listening, cultural sensitivity, and respect for members and families from diverse backgrounds.

• Strong interpersonal and communication skills with the ability to interact effectively with members, families, providers, community organizations, and interdisciplinary team members.
• Ability to establish rapport with members and demonstrate empathy and cultural sensitivity.
• Strong organizational and administrative skills with attention to detail.
• Ability to prioritize multiple assignments and meet established deadlines.
• Ability to work independently within established procedures and as a member of an interdisciplinary team.
• Strong documentation and computer skills.
• Ability to identify social and non-clinical barriers to care and appropriately communicate or escalate concerns.
• Knowledge of community resources, governmental agencies, entitlement programs, and social service systems.
• Understanding of social determinants of health and their impact on access to care and health outcomes.
• Ability to perform structured member screenings and gather relevant social and administrative information.
• Ability to maintain confidentiality and comply with organizational policies and applicable privacy requirements.
• Knowledge of basic care coordination and resource navigation principles.

• Bachelor’s degree in Social Work (BSW) from an accredited social work program required.
•  New York State BSW-level social work credential/registration
•  Additional training in care coordination, SDOH, Medicaid/community resources, or health care navigation preferred.

• 1–2 years of experience in social services, case management, care coordination, community-based services, health care, or a related setting preferred.
• Experience working with diverse populations and connecting individuals to community resources preferred.
• Experience with electronic documentation, data entry, member outreach, or health care coordination preferred.
• Hospital, health plan, managed care, discharge planning, or community-based experience preferred but not required.

Department: Clinical Services
This is a non-management position
This is a full time position