Social Worker Care Coordinator

Health Care Partners, IPA and Health Care Partners, MSO together comprise our health care delivery system providing enhanced quality care to our members, providers and health plan partners. Active since 1996, Health Care 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.

• 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,…