Care Coordinator - Adolescent Health

Job Title: Care Coordinator - Adolescent Health

The Mount Sinai Adolescent Health Center (“MSAHC” or the “Center”) works to break down racial, social and economic barriers to health care and wellness for young people by providing vital services - high quality, comprehensive, integrated and confidential - for all who come to the Center or school-based health facilities, at a low cost to them. The MSAHC advances adolescent and young adult health as a national imperative by serving as a leading center of clinical care, specialized training, innovative research and advocacy. 

The Care Coordinator will provide trauma-informed services guided by a health equity framework, promoting culturally and developmentally appropriate care for at-risk adolescents (ages 10–26) and their families in an integrated medical and mental health primary care setting at MSAHC. The care coordinator will assess and address patient needs, especially those related to accessing concrete support (e.g. housing, food, legal and educational support). They will actively partner with patients to identify support and solutions, involving them in decision-making about their care and work to develop goals that are measurable, attainable, and tailored to the individual, while also addressing any challenges that arise. 

This role emphasizes whole-person care by integrating behavioral, medical, and social support to address mental health, substance use, psychosocial challenges, and health-related social needs that impact patient outcomes.  The Care Coordinator also engages families and caregivers as necessary to support follow-through and healthy adolescent development. Services are trauma-informed and guided by a health equity framework, promoting culturally and developmentally appropriate care for diverse adolescent populations. 

• Care Coordinator will be assigned patient referrals and will complete screening for the purpose of identifying needs (food, housing, legal, educational support).
• Facilitation of appointment scheduling for dental and optical services (identified by care coordinator during assessment or by primary care team) at the Adolescent Health Center.
• Coordinate referrals to specialty behavioral health, substance use treatment, and community resources.
• Collaborate with primary care providers, behavioral health clinicians, psychiatric consultants and community resources.
• Identify and address social determinants of health (SDOH) affecting adolescents, such as housing instability, food insecurity, transportation, and safety concerns.
• Monitor progress over time, adjust care plans in collaboration with the primary care team, and promote resilience and healthy coping strategies.
• Engage caregivers and families in care planning and education, respecting confidentiality and adolescent consent laws.
• Participate in case reviews, interdisciplinary care team meetings, and quality improvement initiatives.
• Document screening/assessments, and outcomes accurately in the EHR.
• Track follow-up appointments and ensure continuity of care.

• Bachelors degree (e.g., BSW, BA).
• Experience in adolescent behavioral health, case management, primary care, or community health.
• Attend Epic Scheduling Training.
• Excellent engagement, assessment, and collaborative skills, with ability to work flexibly in a high-volume, fast-paced setting.
• Knowledge of adolescent development, Family engagement, advocacy skills mental health, and SDOH.
• Strong communication, care coordination, and documentation skills.
• Knowledge and practice of Motivational Interviewing (MI) to engage adolescents and families, support behavior change, and promote self-efficacy.
• Experience working with underserved youth populations.
• Experience in integrated or collaborative care models preferred.
• Bilingual skills (English-Spanish) preferred.

, 186 - Social Services - MSH, Mount Sinai Hospital