Care Coordination Social Worker

The Central Florida Behavioral Health Hub (CFL-BHH) Care Coordination Social Worker works within the context of the Central Florida Behavioral Health Hub, from a team approach, and in partnership with providers, to assist families in timely access to needed mental, emotional, behavioral health care. The CFL-BHH 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 treatment. Assisting and collaborating with larger CFL-BHH team during team meetings, case consultations, trainings, and FL DOH-led meetings, trainings and activities as well as outreach to provider groups and the community.

The position is responsible for the following:

• Actively monitor and update the CFL-BHH Clinical Tracking Database and Nemours Electronic Health Record (EHR) to identify new referrals and manage existing referrals to the CFL-BHH.
• Initiate contact with families referred to the CFL-BHH 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 CFL-BHH Clinical Tracking Database assessment measures like PSC-17 and satisfaction surveys. Assist team in exporting CFL-BHH data to excel or another format deemed by FL DOH.
• Identify families who are in need of immediate assistance, providing immediate referral to emergency services including, when necessary, Mobile Response Teams.
• Actively engage in ongoing collaboration with CFL-BHH team through meetings, trainings, 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 CFL-BHH at Nemours and within the community. Provide timely feedback to referring providers, behavioral health providers, and CFL-BHH team.
• Other duties as assigned.

• Bachelor Degree in Social Work required.
• Minimum six (6) years of social work experience required.