Community Care Coordinator

Job Summary

Licensed Social Work Care Coordinator will provide short‑term care coordination services to individuals and families utilizing MD Medicaid insurance. The coordinator will receive referrals from various sources, assess client needs, and partner with Medicaid Managed Care Organizations, providers, public health and community resources to address barriers to care. The coordinator will also serve as a team leader, providing best practice and interventions to resolve complex psychosocial and behavioral health conditions and needs.

• Participate in professional development opportunities that build effectiveness in client engagement, motivational interviewing, trauma‑informed outreach strategies.
• Participate in local/state meetings, conferences, community meetings.
• Participate in city‑wide initiatives/groups/committees as applicable.
• Consistent and timely communication with supervisor – SW Program Manager.
• Act as Team Lead, host team meetings with outreach staff members to discuss complex cases, best practices, and resource sharing.
• Initiate client outreach via telephone or home visit within 5‑10 days of receipt of a referral.
• Outreach clients with medical or psychosocially complex needs; assess and provide education of Medicaid benefits and services, re‑connect recipients to medical home, Managed Care Organization, and link to covered benefits.
• Consult with other community agencies to identify potential resources for resolving social determinants of health needs.
• Connect and collaborate with providers, hospitals, community‑based organizations, MCO case managers and other professionals to address and resolve client need.

• Assess, triage and refer clients to a variety of available resources to reduce barriers to wellness, including B’More for Healthy Babies Centralized Intake, home visiting, WIC, Safe Sleep, etc.; appropriate MCO incentive programs and case management, medical assistance transportation.
• Provide linkage and coordination to OB, MCO, pediatric or primary care, postpartum care, dental care, behavioral health, specialty care, as well as linkage to the Maryland Medical Care Programs as needed.
• Maintain a monthly minimum success rate of 70%.
• Maintain a monthly minimum on‑time case closure rate of 90%.

• Document all outreach activities according to standard operating procedures in the HCAM electronic medical database.
• Document client assessments, activity, service plans and resolutions; prepare narrative and statistical reports.
• Provide Service Response letters to referring entities at the time of case closure.

• Complete and submit timesheets timely and accurately.
• Complete all required training courses as assigned.

• Additional duties as assigned.

• Bachelor’s degree in a related area;
  Human Services, Social Work or Health Education from an accredited college or university preferred but not required.
• Community Health Worker certification a plus; willingness to undergo certification training within 1 year of employment.
• Minimum of 3 years of related experience.
• Relevant clinical experience providing services to pregnant women and/or infants, preferably in a public health/community setting.

• Demonstrated knowledge in community outreach and Medicaid system navigation.
• Demonstrated knowledge and experience working with Health Choice Medicaid recipients and Managed Care Organizations.
• Organizational and problem‑solving skills.
• Strong knowledge of community resources.
• Proven ability to work efficiently and meet deadlines.
• Excellent oral and written interpersonal and communication skills required.
• Strong computer literacy skills, specifically with MS Word, Excel, Outlook and SharePoint (365).
• Ability to work independently and as part of a team to achieve project success in outreaching clients identified for care coordination.

In compliance with Maryland’s wage transparency requirements, the compensation for this role has been included in the posting. Additionally, the benefits package includes vacation, sick, personal, and mental health leave, a…