Behavioral Health Care Coordinator

About the role

Imagine Pediatrics is a tech enabled, pediatrician led medical group reimagining care for children with special health care needs. We deliver 24/7 virtual first and in home medical, behavioral, and social care, working alongside families, providers, and health plans to break down barriers to quality care. We do not replace existing care teams; we enhance them, providing an extra layer of support with compassion, creativity, and an unwavering commitment to children with medical complexity. The primary location for this role is remote, and expected schedule requirements are Monday to Friday, 8:00am - 5:00pm eastern and 10:30 am - 7:00pm eastern.

Responsibilities

• Monitor high-risk pediatric patients (up to 21 years old), including those recently discharged from the hospital, ensuring appropriate follow-up and assistance with meeting resource needs (food, housing, etc).
• Conduct comprehensive assessments to address behavioral, social, emotional, and systemic needs of patients and families; provide referrals based on identified needs; and ensure caregivers and patients receive prompt, coordinated communication.
• Perform daily tracking of family needs, continuously evaluate the effectiveness of the patient/family care map, and modify plans based on evolving needs and goal progression.
• Maintain timely, accurate clinical documentation for each family; utilize Athena and other internal systems to close patient visits and charts within required timeframes.
• Provide interventions aligned with the social, emotional, and physical needs of patients and caregivers, including de-escalation of mental health crises, behavioral issues, and family conflict; escalate high-risk patients through appropriate pathways.
• Facilitate case management requiring clinical expertise across various systems, helping patients and families navigate the complexities of mental health diagnoses.
• Research and resource validated external services to meet behavioral and social needs, including social services agencies and behavioral health specialists.
• Provide psychoeducation on mental health diagnoses, treatment progression, the importance of treatment adherence, and related topics as appropriate.
• Collaborate regularly with external care team members, including school systems, specialists, and respective state department of child welfare as needed.
• Participate in scheduled interdisciplinary team consultations to monitor patient progress.
• Represent Imagine Pediatrics professionally to patients, families, providers, and the broader community.
• Perform other duties and responsibilities as assigned by manager.
• What You Bring & How You Qualify
• Masters' degree with major course work in social work or related field required
• Provisional licenses (LMSW, PLPC, LAMFT) preferred
• Minimum 3-5 years of post-graduate experience in health care social work/Case management in behavioral health Required.
• Experience working with pediatric population and family systems required
• Proficiency in motivational interviewing practices and/or techniques; goal setting and intervention; assessment of needs
• Knowledge of social work including crisis prevention and intervention
• Experience with providing telehealth services
• Knowledge of MS Office Suite and ability to work in online platforms
• Bilingual Spanish strongly preferred
• Strong knowledge of behavioral health principles and practices
• Proficient in trauma-informed care practices
• Strong knowledge of mental health common signs and symptoms and able to identify difficulties with coping
• Role is remote with 10% travel necessary for training/education purposes
• Ability to work afternoons and evenings
• What We Offer (Benefits + Perks)
• We provide these additional benefits and perks:
• Competitive medical, dental, and vision insurance
• Healthcare and Dependent Care FSA; Company-funded HSA
• 401(k) with 4% match, ve

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