Hybrid care manager position. This role will do in-person visits in Sussex County, DE and Dover, DE. The Care Management Social Worker (CM SW) will assist patients and families in identifying social, emotional and environmental needs that may impact the ability to maintain healthy behaviors and disease management. The CM SW will assist in connecting patients and families with available, appropriate resources and services through the provision of a full spectrum of transition planning and social work services. The CM SW will identify and monitor pediatric patient needs in collaboration with the clinical team around care coordination. She/he will collaborate with the patient/family, physicians, staff and other health care professionals across the continuum to provide ca