Care Management Coordinator - Healthy Steps Specialist MSW

Job description

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