Care Coordinator – LC/MSW

Associates in Family Medicine, P.C.

The Care Coordinator must be:

  • Licensed MSW (LCSW preferred)


The MSW Care Coordinator will be an integral part of the Care team working alongside clinical support staff, front desk staff and providers to identify and reduce barriers to optimal healthcare. You will be promoting optimum health through a variety of methods including: one-on-one conversations, connecting patient to community and internal resources and utilize data to identify patient needs as well as effectiveness of care management interventions.



Include, but are not limited to, the following. Other duties may be assigned.

  • Implement systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations.
  • Support patients during transitions of care.
  • Maintain required documentation for all care coordination activities. Collect required data and utilize data to adjust patient treatment plans.
  • Establish rapport with patients and care teams to assist with transitions of care, assessing patient needs and goals, responding to changing patients’ needs, supporting patients’ self-management goals and working to align resources with patient and population needs.
  • Provide patient education for improved medical management
  • Discuss Advanced Directives with patients and families
  • Address behavioral health needs to patients in the primary care office
  • Assess mental health needs and suicide risk in patients and provide safety planning to patients in crisis
  • Provide counseling and support for health behavior change
  • Employ motivational interviewing strategies and other evidence based strategies to move patient closer to healthy behaviors
  • Collaborate with primary care providers to promote best practices in team based care
  • Utilize creative problem-solving skills to address unique barriers to health.