As one of the nation’s leading pediatric health care systems, Nemours is committed to providing all children with their best chance to grow up healthy. We offer integrated, family-centered care to more than 300,000 children each year in our pediatric hospitals, specialty clinics and primary care practices in Delaware, Florida, Maryland, New Jersey and Pennsylvania. Nemours strives to ensure a healthier tomorrow for all children – even those who may never enter our doors – through our world-changing research, education and advocacy efforts. At Nemours, our Associates help us deliver on the promise we make to every family we have the privilege of serving: to treat their child as if they were our own. 

The Care Coordinator works within the context of a primary care medical home, from a team approach, and in continuous partnership with families and physicians to promote: timely access to needed care, comprehension and continuity of care, and the enhancement of child and family well being. Addresses gaps in care and promotes timely access to appropriate care, increasing the utilization of preventative care and healthy behaviors to improve the health of the population at risk.

• Assist with or promote the identification of patients in the practice with special health care needs;  add them to the registry and use the registry to plan and monitor care.  Monitors chronic/preventive patient registries/lists and Gap in Care reports to assist in getting patients the appropriate appointments and/or interventions.
• Initiate family contacts; create ongoing processes for families to determine and request the level of care-coordination support they desire for their child/youth or family member at any given point in time.  Identify patient and family needs and unmet needs, strengths and assets.  May facilitate or assist with Family Advisory Committee.
• Build care relationships among family and team; support the primary care-giving role of the family.  Promotes teams and actively participates in daily huddles.  Organizes workshops/training for teams and patients.
• As a member of the care team, monitor patient care plans with family/youth/team (emergency plan, medical summary and action plan as appropriate).  Contacts identified patients for preventative services and/or pre-visit forms.
• Case management coordination of non-clinical services such as, transportation, referrals, etc. Makes follow up communication to patients/families on non-clinical matters such as confirmation of delivery of equipment, no show appointments, etc.  Follows-up on patient hospitalizations and ER visits as well as identified overdue labs/images in coordination with office clinical staff.
• Serve as contact point, advocate and informational resource for family and community partners/payors.  Referrals to child protective services and appropriate agencies for domestic violence.  Completes forms such as DFS, FMLA, SSI, etc. and writes letters for housing, nursing care, medical necessity, etc.; Research, find and link resources, services, and supports with/for the patient/family.  Arranges for supplies and equipment. Assists with getting insurance coverage for patients without insurance.
• Coordinate inter-organizationally among family, the medical home, and involved agencies.  Identifies community resources and tracks select community and specialty referrals. 
•  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.  Refer patients to early intervention and public health nurses and help office staff and parents navigate through the school system and help with IEPs.
• Promotes/documents Quality Improvement Cycles.  Responsible for generating required data as appropriate.
• Facilitates the NCQA process at the office working in close collaboration with the VBSO and the Medical Home liaison.

Qualifications

• Associates degree required
• Scheduling experience preferred
• Bilingual preferred
• 3-5 years experience with care coordination preferred

Our dedication to professionals who are dedicated to children frequently earns Nemours a spot on the list of top workplaces in the communities we serve. Our Associates enjoy comprehensive benefits, including our unique “Bridge to a Healthy Future” pediatric health plan, an integrated wellness program, opportunities for professional growth, and much more. As an equal opportunity employer, Nemours focuses on the best-qualified applicants for our openings.