Care Coordinator - JHP

jeffersonhealth; Philadelphia (Philadelphia County); On-site; USD 65,000 - 90,000; Full time

Job summary

Jefferson Health in Philadelphia seeks a care coordination professional to support patient-centered, evidence-based, cost-conscious care.

You will perform telephonic outreach, coordinate with PCPs, specialists, and behavioral health, and help patients navigate barriers to care. The role emphasizes NCQA-aligned case management and collaboration across hospital and community resources.

Qualifications

• Associate's degree required; Bachelor's degree preferred.
• 3 years of clinical/case management experience.
• Must present polished professional image; organized and detail-oriented.

Responsibilities

• Provide timely telephonic outreach to members with chronic conditions.
• Coordinate care across primary care, specialists, hospital, and community resources.
• Document barriers to care, priorities, goals, and plans for follow-up.
• Assist primary care and specialist offices in coordinating care and accommodations for language, mobility, or visual limitations.
• Apply knowledge of pathophysiology, ethics, confidentiality to support problem-solving and decision-making.
• Educate members about health care options and available community resources.
• Collaborate with Behavioral Health providers and MCOs to develop interdisciplinary care plans.
• Inform members about Medicaid benefits and provide approved educational materials.

Skills

Case management

Chronic disease management

Care coordination

Education

Associate's Degree

Bachelor's Degree

Job description

Job Details

Works with minimal supervision to ensure that comprehensive, patient-centered quality of care, cost effective patient care is offered for members in need of care coordination. All care coordination follows NCQA standards for Complex Case Management and is based on evidence-based guidelines. Review medication profiles member history verify appropriate testing and facilitate office visits with primary care and specialist physicians for members targeted for care coordination services. Coordinate with hospital and provider office case managers, as applicable, to ensure continuity of care and outpatient services when medically appropriate. Coordinate with behavioral health to ensure continuity of care and develop care plans. Perform outreach, education, and follow-up to members based on criteria determined by Operational Guidelines. Utilize community resources to assist in coordinating care to maximize positive health outcomes. Collaborate with other members of Health Partner Plans to perform targeted outreach directed at improving outcomes through screenings and preventive health. Work with practice sites to remove barriers to care, improve member self-management and improve member outcomes.

Job Description

• Able to work in a constant state of alertness and safe manner.
• Conduct timely telephonic outreach to members who have chronic conditions to improve health outcomes to include but not limited to assisting primary care provider offices in coordinating care of members with complex medical needs, utilizing appropriate assessments in software.
• Coordinating care for members that is member focused, taking into account the members barriers to care and their personal goals, and documentation within the software that captures the members barriers to care, priority goals, plans of care and schedule for follow up.
• Assumes primary responsibility for providing case management for identified members, including home, hospital and provider/ community site visits as appropriate.
• Assist primary care provider offices and specialist offices in coordinating care of members. Facilitates accommodations for members with language, communication, visual, or mobility limitations.
• Applies knowledge of pathophysiology, psychosocial issues, confidentiality, ethical/legal issues, and therapeutic interventions and sources to assist the membership with problem-solving/decision-making that promotes health, improves level of functioning, and decreases inappropriate use of services.
• Educating members concerning their specific health care needs and care options, including palliative care as appropriate, and researching and coordinating care with available community resources.
• Researching and coordinating care with member's behavioral health provider and MCO. Collaborate with Behavioral Health MCO and the members to develop, assist with implementation of, and follow up on interdisciplinary care plans for members with serious persistant mental illness (SPMI).
• Informing members about Health Partners Plans Medicaid benefits and providing approved educational materials to members that support goals and interventions.
• Coordinate and collaborate care with external as well as internal Health Partners Plans resources to meet the individual needs of the member identified by the assessment and subsequent outreach. Refer appropriate cases to departments within Health Partners Plans to assist with quality of care and utilization management.
• Perform internet searches and follow up to date clinical guidelines in coordinating member care and services. Keep current on existing programs within the community as well as the needs of the population.
• Actively participate in multidisciplinary team meetings to represent care coordination program; Meetings include, but not limited to, Medical Director Rounds and BH Collaborative Meeting. Seek guidance from the assigned Medical Director or designee as appropriate.
• Balances the dual roles of advocacy for the member and stewardship of fiscal resources by assisting the member to identify and utilize all available resources.
• Work collaboratively within the Health Care Management department on tasks as needed. Participates in multidisciplinary and interdepartmental collaboration, reporting and special projects as assigned.
• Support Health Partners Plans mission
• Other duties as assigned that may include but not limited to performing responsibilities of other HPP care management units.

Education Required - Associate's Degree

Education Preferred - Bachelor's Degree

Experience - Required - 3 years current clinical/case management experience

Knowledge, Skills and Abilities - Required - Must present polished professional image. - Understanding of managed care delivery systems. - Ability to work and communicate effectively with co-workers, members, and providers. - Must be organized, detailed oriented, and capable of handling multiple issues. - Excellent telephone and verbal/written com