Clinical Care Coordinator - Sala Care Coordination Program *MSW & LCSW required*

NYU Langone Health is a fully integrated health system that consistently achieves the best patient outcomes through a rigorous focus on quality that has resulted in some of the lowest mortality rates in the nation. Vizient Inc. has ranked NYU Langone the No. 1 comprehensive academic medical center in the country for three years in a row, and U.S. News & World Report recently placed nine of its clinical specialties among the top five in the nation. NYU Langone offers a comprehensive range of medical services with one high standard of care across 6 inpatient locations, its Perlmutter Cancer Center, and over 320 outpatient locations in the New York area and Florida. With $14.2 billion in revenue this year, the system also includes two tuition-free medical schools, in Manhattan and on Long Island, and a vast research enterprise with over $1 billion in active awards from the National Institutes of Health.

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Position Summary:
We have an exciting opportunity to join our team as a Clinical Care Coordinator,Sala.

In this role, the successful candidate The Care Coordinator leads the psychosocial components of follow up care, including post-discharge assessments, identification to barriers of care, short term adjustment counseling, and connection to community and medical resources. Utilizing a trauma-informed, family-centered approach, the role advocates for patients and families, promotes self-management, and coordinates services over a 3-12 month period. The Care Coordinator collaborates closely with primary care, subspeciality providers and their HCH social workers, integrated behavioral health, and community partners to ensure continuity, alignment of care plans, and improved patient and family outcomes.

Job Responsibilities:

Psychosocial Assessment, Identification of Barriers, and Resource Identification:

• Facilitate clear handoff process between inpatient team, family, and Sala Care Coordination team; co-lead discharge rounds to connect with family prior to discharge
  • Conduct robust psychosocial assessment via telehealth within 24-72 hours post-discharge and subsequent psychosocial assessments over subsequent encounters over the following 3-12 months
    • Conduct psychosocial assessments to evaluate needs and challenges
      • Identify and connect patients to community resources tailored to their specific needs
      • Escalate any medical concerns to Nurse Coordinator
      • Assess effectiveness of plan
      • Help facilitate longer-term resource planning and linkage for families who require ongoing supports beyond the immediate post-discharge period

Provide short term illness adjustment counseling to support

• Utilize a family-centered, trauma-informed approach to assess psychosocial stressors and provide supportive counseling to children and families coping with complex illness, hospitalization, and transitions in care
• Develop individualized plans to alleviate indicated stressors by mobilizing community resources that are pertinent to patient/family needs
• Provide counseling and interventions concerning: impact of diagnosis, chronic/life threatening illness/treatment, end of life care, impact on education and work, abuse or neglect, parenting, financial supports, impact on family dynamics, mental health, alcohol/substance abuse; health care coverage, and home care services

Provision of Resources and Coordinated Services:

• Connect families to community resources/programs to alleviate psychosocial burdens related to medical, emotional, and economic stressors, including but not limited to: insurance funded home care supports for short and long term care needs, rehabilitation therapies, benefits and entitlements, home and vehicle modifications to accommodate medical needs, family support services, and educational advocacy (e.g., Early Intervention, Preschool, School-Age, and Young Adult services)

Promoting Patient Self-Management:

• Help families and patients build self-management capacity through access to resources, education, problem-solving support, and ongoing psychosocial guidance
• Reinforce family-centered care planning that empowers caregivers to manage their childs care more confidently across settings
• Act as a central advocate for patients and their families, ensuring social and psychosocial needs are met

Collaboration and Integrated Support:

• Facilitate coordination of social support services to ensure patients and families achieve self-management of care

• Serve as the primary psychosocial liaison across inpatient, outpatient, and community settings to ensure family needs, preferences, and barriers are communicated to the interdisciplinary team

• Partner closely with the Nurse Coordinator to translate complex medical plans into actionable, family-centered community care plans that address psychosocial, cultural, and socioeconomic factors impacting adherence

• Proactively identify and communicate psychosocial risks or changes in family circumstances that may impact medical care, escalating concerns to the Program Manager and care team as appropriate

• Follow-up with primary care and subspecialist team to understand updates, the current state of care, and any potential barriers impacting the patients health
• Partner with the Nurse Coordinator in a shared care model from discharge through program transition, with joint responsibility for continuity, family engagement, and coordination across settings
• Role reports to Assistant Director, Social Work
• Performs other duties as assigned

Minimum Qualifications:
To qualify you must have a Masters degree in Social Work (MSW) from an accredited school of social work
Current New York State licensure as a Licensed Clinical Social Worker (LCSW) required
Minimum of 3 years of pediatric social work experience required; experience with medically complex children, chronic illness, hospital-to-home transitions, and family-centered care strongly preferred
Experience conducting psychosocial assessments, crisis assessment, brief counseling, and resource coordination in pediatric hospital, ambulatory, or complex care settings required
Demonstrated experience addressing social determinants of health, caregiver stress, adherence barriers, and access to community-based supports and entitlements
Experience collaborating across multidisciplinary teams, including physicians, APPs, nursing, behavioral health, case management, schools, and community agencies required.

Required Licenses: Lic Clinical Social Worker

Qualified candidates must be able to effectively communicate with all levels of the organization.

NYU Langone Health provides its staff with far more than just a place to work. Rather, we are an institution you can be proud of, an institution where you'll feel good about devoting your time and your talents.

At NYU Langone Health, we are committed to supporting our workforce and their loved ones with a comprehensive benefits and wellness package. Our offerings provide a robust support system for any stage of life, whether it's developing your career, starting a family, or saving for retirement. The support employees receive goes beyond a standard benefit offering, where employees have access to financial security benefits, a generous time-off program and employee resources groups for peer support. Additionally, all employees have access to our holistic employee wellness program, which focuses on seven key areas of well-being: physical, mental, nutritional, sleep, social, financial, and preventive care. The benefits and wellness package is designed to allow you to focus on what truly matters. Join us and experience the extensive resources and services designed to enhance your overall quality of life for you and your family.

NYU Langone Health is an equal opportunity employer and committed to inclusion in all aspects of recruiting and employment. All qualified individuals are encouraged to apply and will receive consideration. We require applications to be completed online.

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NYU Langone Health provides a salary range to comply with the New York state Law on Salary Transparency in Job Advertisements. The salary range for the role is $70,481.61 - $121,580.64 Annually. Actual salaries depend on a variety of factors, including experience, specialty, education, and hospital need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.

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