Complex Care Manager

Thomas Jefferson University•Philadelphia, PA

17h•Onsite

About The Position

Serves as a regional liaison to the Care Management Department and, when necessary, assumes the primary Care Manager's role. The role supports complex patients who need advanced discharge planning because of barriers such as extended hospital stays, guardianship or legal interventions, behavioral health comorbidities, homelessness, substance use disorders, or medically complex conditions requiring coordination with state and local agencies. The Complex Care Manager drives interdisciplinary collaboration and leads care plan execution for patients with highly challenging psychosocial needs, supporting safe, ethical, and timely transitions across the care continuum. The position coordinates with patients, families, clinicians, interdisciplinary teams, and external agencies to address complex psychosocial or continuing-care needs and resolve discharge-planning challenges. It also supports patient assessment and high-risk screening for resource management, monitors complex discharge plans, and facilitates movement to alternate levels of care within the hospital.

Requirements

Master’s degree in Social Work.
Three years of inpatient Care Management experience in an acute care setting.
Ability to work independently and set priorities to coordinate care plans efficiently under value-based care constraints.
Interpersonal skills to negotiate with families, patients, physicians, and third-party payers for an optimal plan.
High degree of initiative and decision-making skills.

Nice To Haves

Knowledge of community agencies that provide patients and families with appropriate choices and options for post-hospital care or admission prevention.
Knowledge of the guardianship process.
ACM (Accredited Case Manager) certification from the American Case Management Association within three years, or CCM (Certified Case Manager) certification from the Commission for Case Manager Certification within three years.

Responsibilities

Coordinate family and/or interdisciplinary meetings with specialties and external agencies to promote movement through the continuum.
Collaborate with admitting and emergency department physicians, hospitalists, nursing, and other clinical ancillary staff on patient assessments and high-risk screening for resource management.
Consult with patients and families who have complex psychosocial or continuing-care needs that may obstruct a safe transition to a lower level of care or discharge to the community.
Make referrals to population health teams, payer care coordination teams, or external agencies when appropriate.
Work with the inpatient Care Management team to monitor complex discharge plans and resolve challenges.
Facilitate patient movement to alternate levels of care within the hospital through coordination and ongoing oversight with patients, families, physicians, and the interdisciplinary team.
Attend assigned Care Progression Rounds, Complex Care Rounds, or specific patient meetings and contribute the Complex Care Manager role as an adjunct to the team's clinical expertise.
Interact with co-workers, visitors, and other staff consistent with Jefferson's values.

Benefits

Medical insurance, including prescription coverage
Supplemental insurance
Dental insurance
Vision insurance
Life and AD&D insurance
Short- and long-term disability coverage
Flexible spending accounts
Retirement plans
Tuition assistance
Voluntary benefits, including access to group insurance rates and discounts
Tuition discounts at Thomas Jefferson University after one year of full-time service or two years of part-time service
Medical insurance, including prescription coverage, is available to all colleagues, including those working less than part-time.