Care Coordinator


The Care Coordinator is a Social Worker who facilitates patient continuity of care with the healthcare team. Under the clinical direction and oversight of the Primary Care Physician, the Care Coordinator coordinates care for high risk/complex patients by collaborating with the patient, family, physician, nurses, and other members of the healthcare team to identify needs and expedite appropriate, cost effective care. The Social Worker partners with the RN Care Coordinator to facilitate the care models of DVACO by coordinating services and community resources and meeting member socioeconomic needs to support the quality of life. S/he assists in the development of the patient’s care plan and collaborates with the Primary Care Physician to provide leadership in issues of outcomes management, disease management and prevention, and development of improved strategies to benefit high risk patients. The Care Coordinator may serve as the patient’s primary conduit to the primary care provider as they help coordinate necessary services both within and outside the practice, coordinating care from a variety of sources – physicians, specialists, home care providers, rehab centers, pharmacists, etc. They will engage patients and encourage them to take an active role in their health by providing them with the tools necessary to make healthy lifestyle choices and adopt life-long healthy behaviors. The social worker will serve as an advisor to the clinical team for health and human services resources as well as guardianship and behavioral health issues.


Patient and Family

  • Empowers and engages patients and families to represent themselves and advocates the patient’s perspective.
  • Recognizes the holistic interrelationship that exists within and across the health system and consistently negotiates the best outcomes for the patients and families
  • Ensures that the patient and family members experience seamless and safe transitions of care from encounter to encounter
  • Develops patient self-management goals, and, with colleagues, monitors the progress of the goals and updates as appropriate
  • Ensures that patients and families receive education on health and wellness activities, disease process and interventions, medications, next steps, and other critical factors in overall health maintenance and improvement
  • Supports patients in making and getting to healthcare appointments
  • Responsible for following patients’ long term if needed to ensure appropriate resources are obtained and secure.

Cross Continuum Care Facilitation and Coordination

  • Responds quickly to case referrals, identifies support and intervention activities to support health both in the home and community, and assists with trying to prevent disease progression
  • Coordinates with law enforcement and Adult Protective Services in situations of suspected abuse or neglect, and domestic violence
  • Works with patients on Advance Directives (ADs), Durable Power of Attorney (DPOA), and identification of a proxy if needed
  • If needed will complete preadmission screening and annual resident review (PASARR) for individuals at home needing skilled care or nursing home placements
  • Ensures that appropriate resources are identified and scheduled for patients who require continuing psychosocial/mental health interventions or therapy
  • Communicate regularly with various agencies, foundations, programs, charities, and businesses to assist patients with their care plan needs
  • Orchestrates and synchronizes care between multiple care delivery sites and multiple caregivers and quickly and efficiently mobilizes resources to support patients and families through the continuum of care safely, efficiently and effectively
  • Document care coordination activities based on the DVACO clinical platform in a timely and accurate manner; assuring the DVACO the ability to comply with professional documentation standards, compliance of DVACO contracts, and quality data collection
  • Works quickly to address barriers and challenges associated with cross continuum care coordination and engages colleagues and staff in “hard wiring” appropriate solutions
  • Accountable for accurate and timely documentation
  • Assists and collaborates in the management of patients with chronic diseases following established protocols and interventions
  • Successfully engage members to develop an individualized plan of care to promote healthy lifestyles, close gaps in care, and reduce unnecessary ER utilization and hospital readmissions. Develop and coordinate the individualized plan of care with the member, member’s family, providers and community agencies as applicable. Involve other staff to support the individualized plan of care based on identified needs of the member
  • Ensures absolute compliance with CMS and other regulatory initiatives
  • Assesses total health status, identifies, addresses and includes in the plan of care, contributing factors such as obesity, age, diabetes, medications, etc.
  • Ensures that Advanced Care Planning is offered to patients and families as applicable
  • Coordinates healthcare interventions for populations with significant health conditions in which self-management efforts are critical
  • Perform duties and responsibilities in accordance with the philosophy and standards of the DVACO, including conveying courtesy, respect, enthusiasm, and a positive attitude through contacts with staff, health plan members, peers, and external contacts.
  • Responsible to update and research community resources


  • Works with community agencies to arrange services for patients with chronic or complex care needs, or to encourage general wellness and health
  • Develops significant population savvy, ensuring that services and interventions address the needs of the market demographic, and are sensitive to cultural and ethnic practices and beliefs
  • Understands community health challenges and works with leaders and division staff and colleagues to develop and implement practices, education programs, and other strategies to improve the health of the community and to promote continuous improvement in health status across the continuum
  • Establishes significant functional relationships with community providers and community service agencies, monitoring the integrity of care and services
  • Visits community care providers to develop rapport, understand service offerings, and insure quality and consistency of services

Physician Engagement/Alignment

  • Engages physicians and staff in care improvement and resource management activities
  • Provides consultation to physicians and staff regarding the patient’s psychological, financial, developmental, family, and other pertinent challenges
  • Partners with and supports physicians and staff in patient care activities and post-acute care planning
  • Proactively communicates with physicians and staff
  • Serves as a resource to physicians and staff on health industry trends, rules, regulations, and resources in both the home and community setting


  • Ensures that the company’s mission, vision, and values are actualized
  • Provides exemplary customer service to the patient, family, physician, and care team members
  • Models and orchestrates consistent, professional communications and maintains consistent and proactive communication patterns with colleagues and staff
  • Establishes rapport and relationships with community physicians, physician practices, post-acute providers, and community agencies
  • Responds positively to change
  • Delegates responsibilities appropriately but remains accountable for outcomes
  • Excels in, and utilizes, both tactical and strategic communication to prevent duplication and omission of critical information, to expose concerns and issues, and develop trusting relationships.
  • Immediately addresses and reports all barriers and challenges impacting safety, quality, cost or efficiency of providing services.

Assessment & Analysis

  • Develops a deep understanding of population health data, proactively reviews data, and engages colleagues across the continuum to improve care
  • Maintains constant awareness of performance and service outcomes data, inclusive of financial, operational, process, value, and relational coordination measures
  • Works with colleagues to significantly decrease ER Visits, and hospital admissions
  • Continues to research, learn and assist with cost effect ways to manage and assist the DVACO populations.
  • Document care coordination activities based on the DVACO clinical platform in a timely and accurate manner; assuring the DVACO the ability to comply with professional documentation standards, compliance of DVACO contracts, and quality data collection.


  • Attains significant knowledge of Population Based Care, Clinical Integration and Accountable Care
  • Leads at least 2 educational programs per year to her colleagues
  • Supports research activities at the DVACO
  • Stays abreast of CMS measures, National Patient Safety Goals (NPSGs), publicly reported outcomes
  • Develops and maintains significant knowledge of relevant medical/legal issues impacting patient care, including advanced directives, and elder abuse
  • Responsible to assist with Quality Reporting for MSSP
  • Extensive knowledge in community and in home resources for a multitude of issues, illnesses, and needs for patients within the tristate area and surrounding counties.

Social Work –Specific Competencies

  • Understanding of medical and psychiatric nomenclature
  • Knowledge of key medical diagnosis that frequently involve concomitant psychosocial problems
  • Knowledge of Federal and State statutes regarding patient privacy and the confidentiality of patient information
  • Knowledge of signs/symptoms of abuse/neglect and State reporting requirements and procedures
  • Knowledge of and experience with Pennsylvania Mental health law and procedures regarding voluntary and involuntary inpatient treatment
  • Excellent Behavioral-assessment and interpersonal skills


Education: Master’s Degree in Social Work from CSWE (Council on Social Work Education) accredited program.

Licensures & Certifications:
Case Manager (CCM) certification (preferred)


  • 5 years experience in hospital or community clinic, home care, discharge planning, and/or case management required
  • 3 years experience in a managed care environment preferred
  • Prior ACO experience preferred
  • Minimum 2 years experience working with frail or elderly population
  • Strong behavioral health background
  • Ability to interact with physicians and other health care professional in a professional manner required
  • Ability to work independently
  • Computer proficiency required.
  • Excellent verbal and written communication and interpersonal skills required
  • Ability to prioritize daily tasks and caseload activities to meet patient needs and turnaround times
  • Knowledge of managed are models financial reimbursement systems, clinical case management processes and utilization management issues
  • Knowledge of NCQA (PCMH) guidelines for care management


  • Occasional travel within 50 mile radius of Philadelphia.
  • Possibility of offsite meetings at provider offices, community agencies or other clinical settings. Occasional seminars or training sessions in the Philadelphia area.

Equipment Used:

Basic office equipment. Applicable systems and software packages.

  • Microsoft Outlook
  • Microsoft Excel
  • Microsoft Word
  • EPIC or other EMR equivalent
  • Wellcentive
  • Patient Ping
  • Milliman Care Guidelines

Please apply to job id 50294. No agency calls please. Applicants must certify that they have not used tobacco products or nicotine in any form in the 90-days prior to submitting an application to Main Line Health. This will be verified during pre-employment testing.

We are an equal opportunity employer.