EMBEDDED CARE COORDINATOR (Pediatric Practice)

Description We are seeking a highly organized, proactive, and compassionate Embedded Care Coordinator to join our pediatric practice. This role is IN-PERSON and supports children, adolescents, and families by identifying and addressing social determinants of health (SDOH) that impact wellbeing, treatment adherence, development, and access to care. The Embedded Care Coordinator will work closely with providers, behavioral health staff, and families to connect patients with community resources, coordinate care across systems, and remove barriers related to housing, food insecurity, transportation, insurance, behavioral health access, and other family stressors. This position is ideal for someone who thrives working independently, takes initiative without needing close supervision, and can manage a high volume of moving parts with exceptional attention to detail.

Key Responsibilities:

Conduct SDOH screenings and assess family needs through in-person, phone, and virtual outreach Provide resource navigation for housing, food, transportation, utilities, childcare, insurance, and financial assistance Coordinate referrals to community agencies and specialty services Track referrals, outcomes, follow-up tasks, deadlines, and family engagement with meticulous documentation in EHR (Epic) Collaborate with pediatricians, nurses, therapists, and on-site Educational Consultant to ensure coordinated care Maintain updated knowledge of local community resources and eligibility requirements Assist families in completing forms, applications, and connecting to services Escalate urgent safety or psychosocial concerns to appropriate clinical staff promptly Identify gaps in systems/processes and independently develop solutions to improve workflow and patient support Participate in team meetings where appropriate and quality improvement initiatives Requirements Bachelor's degree in Social Work, Human Services, Public Health, Psychology, Sociology, or related field Experience in care coordination, case management, healthcare navigation, social services, or pediatric/family support Strong knowledge of social determinants of health and community resource systems Excellent organizational skills with ability to manage multiple families and priorities simultaneously Demonstrated ability to work independently, problem-solve, and take initiative Ability to travel between three pediatric locations, all within the North Shore Strong written and verbal communication skills Comfortable working with diverse families in a fast-paced healthcare setting Proficiency with electronic medical records (or a willingness to learn) and standard office technology Experience in pediatrics, family medicine, behavioral health, or community health centers Familiarity with Medicaid/MassHealth and insurance navigation Bilingual/multilingual skills strongly preferred Key Traits for

Success:

Incredibly organized and detail-oriented Self-starter who sees what needs to be done and does it Calm under pressure Warm, respectful, and family-centered Resourceful and persistent Strong boundaries and professionalism