Care Coordination Social Worker (Finance)

Nemours is seeking a Care Coordination Social Worker for our Jacksonville, FL location.

The PATH Care Coordination Social Worker works within the context of the PATH program, from a team approach, and in partnership with providers, to assist families in timely access to needed mental, emotional, behavioral health care and social service's needs. The PATH Care Coordinator will utilize critical thinking skills as well as social worker knowledge and expertise to determine necessary resources for each individual patient and family and assist families in securing the treatment required to optimize patient outcomes. Identify patient and family barriers to necessary treatment and guide families to resources to help them surmount those barriers. Assess gaps in care and promote timely access to appropriate care. Provide support as needed to families while getting them connected to services and/or treatment. Assisting and collaborating with larger PATH, social work, behavioral health hub teams during team meetings, case consultations, training, and activities as well as outreach to provider groups and the community.

Essential Functions

Actively monitor and update the PATH Clinical Tracking Database and Nemours Electronic Health Record (EHR) to identify new referrals and manage existing referrals to the PATH. Utilize health planet dashboard to monitor and manage SDOH and need for referrals and outpatient follow up.

Initiate contact with families referred to the PATH to complete information needed for referral for services, consultation, or both. For those that require services, collaborate with families to determine the level of care-coordination support they desire for their child/youth or family member at any given point in time.

Assess patient and family needs, unmet needs, strengths and assets as well as potential barriers to needed treatment. Assess biopsychosocial needs of at-risk patients, i.e., single parents, substance abuse, complex medical patients, etc.

Identify ideal treatments and resources for children and families based on their needs. Connect children and families to those treatments / resources and track family adherence to those referrals.

Coordinate inter-organizationally among family, the medical home, behavioral health providers and other involved agencies. Provide bi-directional communication between and among the groups.

Research, find and link resources, services, and supports with/for the child and family. Provide families with information about access to insurance and transportation for visits. 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, etc. Refer patients to early intervention and help parents navigate through the school system including help with IEPs when needed.

Monitor and, when necessary, aid patient/families in completion of PATH Clinical Tracking Database (Healthy Planet dashboard) assessment measures like SDOH screeners, Vanderbilt, PHQ-9, GAD-7, and satisfaction surveys. Assist team in exporting PATH data to excel or another format deemed by FL DOH.

Identify families who need immediate assistance, providing immediate referral to emergency services including, when necessary, Mobile Response Teams.

Actively engage in ongoing collaboration with PATH team through meetings, training, case consultations, and quality improvement projects. Actively participate in completing DOH reporting documents including entering, compiling and analyzing data, as well as building spreadsheets and completing forms.

Support the PATH at Nemours and within the community. Provide timely feedback to referring providers, behavioral health providers, and PATH team.

Requirements:

• Bachelor of Social Work is required
• Minimum six (6) months of social work experience required; 1+ year(s) preferred