Complex Care Manager

Jefferson Health Plans • Abington Township, PA

1d

About The Position

Serves as a regional liaison to the Care Management Department and, when necessary, assumes the primary Care Manager's role. This role is activated for complex patients requiring advanced discharge planning support due to barriers such as extended hospital stays (>20 days), 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, ensuring safe, ethical, and timely transitions across the care continuum.

Requirements

• Communicates Effectively
• Customer Focus
• Situational Adaptability
• Values differences
• Advanced knowledge of community-based services, state Medicaid waivers, housing programs, and behavioral health systems.
• Deep understanding of legal processes such as guardianship, involuntary commitment, and capacity determinations.
• Ability to de-escalate complex patient/family dynamics and advocate for the most appropriate and ethical care decisions.
• Skill in conflict resolution, motivational interviewing, and trauma-informed care.
• Proficiency in interdisciplinary collaboration, leading family meetings, and navigating payer challenges related to complex discharge planning
• Master’s Degree in Social Work AND
• 3 years Inpatient Care Management experience in an acute care, ambulatory, and/or community-based setting.
• Ability to work independently, setting priorities to coordinate care plans efficiently under constraints of value-based care.
• Knowledge of Community Agencies required to provide patients and families with appropriate choices and options for post hospital care or prevention of admission.
• Interpersonal skills necessary to negotiate with families, patients, physicians and third-party payers for optimum plan.
• Graduate of an accredited MSW program
• Must maintain licensure and certification in good standing throughout employment
• Care Management Specialty Certification within 2 years of hire
• Excellent verbal and written communication skills.
• High degree of initiative and independent decisionmaking.
• Ability to establish and sustain a positive impact at all levels of the organization.
• Strong working knowledge of community-based behavioral health systems, and complex discharge protocols
• Proficient in navigating payer systems and advocating for coverage of non-traditional discharge needs (e.g., long-term acute care, behavioral health placement, homelessness)
• Demonstrated ability to coordinate with legal services, guardianship court, and local/state agencies for atrisk patient populations.
• High level of emotional intelligence, problem-solving, and resilience in high-stress, ethically complex situations
• Experience using electronic medical records and documentation systems (e.g., Epic)
• Comfortable working independently and as part of an interdisciplinary team to lead and resolve complex care barriers
• Excellent verbal and written communication skills.
• High degree of initiative and independent decisionmaking.
• Ability to establish and sustain a positive impact at all levels of the organization

Responsibilities

• Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.
• Collaborates with admitting physicians, ED physicians, hospitalists, nursing and other clinical ancillary staff to assist with the initial patient assessment and high-risk screen for the purpose of resource management.
• Promotes adherence to clinical protocols through collaboration with the physician and interdisciplinary team to encourage evidence-based interventions relevant to the patient’s reason for admission and immediate acute care needs.
• Coordinates family and/or interdisciplinary meetings with all specialties to promote movement through the continuum.
• Provides consultation for patient/families with complex psychosocial or continuing care needs that may present obstacles for a safe transition to a lower level of care or discharge to the community and makes a referral to ambulatory care and payor care coordination resources when appropriate.
• Works collaboratively with the IPT Care Management team to monitor the progress of completing complex discharge plans and collaborates to resolve challenges.
• Facilitates patient movement to alternate levels of care within the hospital through coordination an ongoing oversight with patient/family, physician, and interdisciplinary team.
• Demonstrates pro-active communication to influence treatment plan and progression of care while advocating on behalf of the patient and organizational stakeholders.
• Attends assigned Care Progression Rounds, Complex Care Rounds or specific patient meetings and promotes CCM role as an adjunct to the team’s clinical expertise.
• Other duties as assigned

Benefits

• Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts.
• Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service.
• All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.
• For more benefits information, please click here

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level