Social Worker Care Coordinator

HealthCare Partners, IPA and HealthCare Partners, MSO together comprise our health care delivery system providing enhanced quality care to our members, providers and health plan partners. Active since 1996, HealthCare Partners (HCP) is the largest physician-owned and led IPA in the Northeast, serving the five boroughs and Long Island. Our network includes over 6,000 primary care physicians and specialists delivering services to our 125,000 members enrolled in Commercial, Medicare and Medicaid products. Our MSO employs 165+ skilled professionals dedicated to ensuring members have access to the highest quality of care while efficiently utilizing healthcare resources.

HCP’s vision is to be recognized by members, providers and payers as the organization that delivers unsurpassed excellence in healthcare to the people of New York and their communities. We pride ourselves on selecting the most qualified candidates who reflect HCP’s mission of serving our members by facilitating the delivery of quality care. Interested in joining our successful Garden City Team? We are currently seeking a Social Worker!

Position Summary: The Social Work Care Coordinator provides administrative support, care coordination, member outreach, resource navigation, and Social Determinants of Health (SDOH) assistance to members across diverse populations. This position works as part of an interdisciplinary care team to identify social and non-clinical barriers that may impact a member’s ability to access care, follow treatment recommendations, or safely transition between care settings.

The Social Work Care Coordinator conducts structured SDOH screenings, gathers psychosocial and social information, connects members and their families with appropriate community resources, and supports care coordination and discharge planning activities. This role collaborates closely with licensed clinical staff, nurses, Medical Directors, and other members of the interdisciplinary care team.

The Social Work Care Coordinator is primarily focused on member engagement, resource coordination, documentation, follow-up, and administrative support.

Essential Position Functions/Responsibilities:

• 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.

Qualification Requirements:
Skills, Knowledge, Abilities

• 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.

Training/Education:

• 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.

Experience:

• 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.

Our website: HealthCare Partners
Base Compensation: $28.00- $33.00 per hour or $60,000.00- $70,000.00 annually
Bonus Incentive: Up to 12.5% annually based on organizational performance
Benefits: Fully paid Medical & Dental employee coverage + robust benefits package (PTO, 401k, FSA, Tuition Reimbursement, etc.)

Equal Employment Opportunity Statement:
HealthCare Partners, MSO is committed to fostering a diverse and inclusive workplace. We provide equal employment opportunities (EEO) to all employees and applicants without regard to race, color, religion, sex, national origin, age, disability, genetics, or any other protected status under federal, state, or local laws. In compliance with all applicable laws, HealthCare Partners, MSO upholds a strict non-discrimination policy in every location where we operate. This policy applies to all aspects of employment, including but not limited to recruitment, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

Job Disclaimer:
The above job description outlines the general scope and responsibilities of the position. It is not intended to be an exhaustive list of duties, skills, or qualifications required. Responsibilities may evolve based on business needs.