Healthy Care Coordinator; LSW

Saint James Health is seeking a Licensed Social Worker (LSW) to serve as the Healthy Steps Care Coordinator, supporting families with children from birth to age three. The Healthy Steps Coordinator works as part of the pediatric care team to promote early childhood development, positive parenting practices, and family well-being through developmental screening, care coordination, brief interventions, and connection to community resources.

This role is embedded within the pediatric clinic and aligns with Saint James Health's mission as a Federally Qualified Health Center (FQHC) to address medical, behavioral, and social

determinants of health.

Care Coordination & Family Support

• Serve as the primary Healthy Steps Care Coordinator for families with children ages 0–3
• Conduct brief, evidence-based screenings related to:
• Child development and milestones
• Family needs and social determinants of health
• Provide short-term, strengths-based interventions and anticipatory guidance to caregivers
• Support families with parenting strategies, behavior concerns, and early childhood development education

Clinical & Pediatric Team Integration

• Work collaboratively with pediatric providers, nurses, medical assistants, and behavioral health staff
• Participate in pediatric team huddles and case discussions
• Assist providers with identifying families who would benefit from Healthy Steps services
• Provide warm handoffs during pediatric visits as appropriate

Referrals & Community Resources

• Connect families to internal Saint James Health services including:
• Behavioral health
• Case management
• Community health workers
• Nutrition and Food Farmacy services
• Refer families to external community-based organizations (Early Intervention, childcare, housing, food assistance, parenting programs, etc.)
• Track referral outcomes and follow up with families to support engagement

Documentation & Compliance

• Document all encounters, screenings, and interventions in Epic EMR
• Ensure documentation meets HRSA, Medicaid, and Healthy Steps program requirements
• Maintain accurate tracking data and reports related to Healthy Steps metrics
• Comply with HIPAA, patient confidentiality, and Saint James Health policies

Program Support & Quality Improvement

• Support implementation and sustainability of the Healthy Steps model at Saint James Health
• Participate in data collection, reporting, and quality improvement activities
• Assist with grant reporting and audits as needed
• Represent Healthy Steps at internal meetings and community events when appropriate

Qualifications

Required

• Bachelor's or Master's degree in Social Work
• Active New Jersey LSW license in good standing
• Experience working with children, families, or early childhood programs
• Strong knowledge of social determinants of health and community resources
• Ability to work effectively in a fast-paced, multidisciplinary healthcare environment
• Proficiency with EMRs (Epic preferred)
• Excellent communication, organizational, and documentation skills

Preferred

• Experience in an FQHC, pediatric, or community health setting
• Familiarity with the Healthy Steps model
• Bilingual (English/Spanish or English/Portuguese) strongly preferred
• Experience with developmental screenings and early childhood interventions