Complex Care Manager

Jefferson Health Plans • Philadelphia, PA

2d • 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 challenging psychosocial needs, promoting safe, ethical, and timely transitions across the care continuum.

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 post-hospital care options or help prevent admission.
• 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 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 about complex psychosocial or continuing-care needs that may obstruct a safe transition to a lower level of care or discharge to the community.
• Refer patients to population health teams, payer care coordination teams, or external agencies when appropriate.
• Work with the IPT 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 promote the Complex Care Manager role as an adjunct to the team's clinical expertise.
• Interact with co-workers, visitors, and other staff consistently with Jefferson's values.

Benefits

• Medical and prescription insurance
• Supplemental insurance
• Dental insurance
• Vision insurance
• Life and AD&D insurance
• Short- and long-term disability insurance
• 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 and prescription insurance access for all colleagues, including those working less than part-time

What This Job Offers

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