Case Coordinator-Pediatrics Primary Care Division-Full-Time-Days

Overview

Description:

The Case Coordinator serves as an integral member of the multidisciplinary pediatric care team, providing comprehensive

psychosocial assessment, care coordination, resource navigation, and advocacy for children with medical complexity and

their families. The position works collaboratively with physicians, advanced practice providers, nurses, therapists, schools,

community agencies, and social service organizations to address social determinants of health, improve access to care,

reduce barriers, and promote optimal health outcomes across the continuum of care.

Responsibilities

Job Requirement:

Develop, Implement and Maintain Individualized Social Plans of Care. Create, update, and monitor comprehensive psychosocial care plans that address behavioral, developmental, educational, financial, and social needs

Manage Transitions of Care, Support patients and communicate with the care team after hospitalizations, emergency department visits, rehabilitation stays, transfers to skilled nursing facilities, out-of-state complex care programs, and transitions between pediatric and adult services.

Serve as the Primary Point of Contact for Families Provide ongoing support, answer questions, facilitate communication, and help families navigate complex healthcare systems and resources.

Educate patients and caregivers regarding available community resources, insurance benefits, government assistance programs, advance care planning, and transition planning.

Assessments - Utilize appropriate screening and assessment tools to determine patient needs (example: crisis screening

tools and the social determinants of health questionnaires). Identify barriers such as transportation, housing instability,

food insecurity, financial hardship, or caregiver burden and connect families with appropriate resources.

Coordinate Community-Based Services and Resources: Assess patient and family needs and facilitate referrals to appropriate medical, behavioral, educational, financial, and social service agencies, including home health, early

intervention, school services, Medicaid waiver programs, SSI, transportation assistance, respite care, and other community supports.

Interdisciplinary Communication - Collaborate with physicians, nurses, specialists, therapists, and community agencies to ensure coordinated care delivery. Write letters for families related to diagnoses, healthcare or school needs, and letters of medical necessity. Participate in interdisciplinary care conferences, family meetings, and care planning discussions to promote coordinated, patient- and family-centered care. Primary point of contact for the Department of Children and

Families, when needed

Document and Track Care Coordination Activities - Document assessments, interventions, referrals, care plans, patient

contacts, and outcomes in the electronic health record in accordance with regulatory, organizational, and payer requirements. Participate in quality improvement initiatives related to children with complex medical needs.

Qualifications

Qualification:

Experience Requirements:

1 year Working with children and/or youth with special health care needs preferred

2 years healthcare setting required

Education:

Minimum Education: Bachelor's degree in social work (BSW), Human Services, Psychology, or a related field. (Social Work degree preferred).

An equivalent combination of education and direct case management or care coordination experience may be substituted on a year-for-year basis.

Additinal Duties:

Additional duties as assigned may vary.

UFJPI is an Equal Opportunity Employer and Drugfree Workplace