Complex Care Manager

Jefferson Health; Pennsylvania; On-site; USD 90,000 - 120,000; Full time

Benefits offered by this job

Medical insurance

Tuition assistance

Life and disability coverage

Job summary

Jefferson Health in the United States is seeking a Complex Care Manager to serve as a regional liaison to the Care Management Department and lead care plan execution for highly challenging psychosocial patients.

The role focuses on advanced discharge planning, coordination with state/local agencies, and interdisciplinary collaboration to ensure safe, ethical transitions across the care continuum.

Qualifications

• Master’s Degree in Social Work required.
• Minimum 3 years inpatient care management experience in an acute care setting.
• Ability to work independently and coordinate care plans under value-based care constraints.
• Strong interpersonal skills to negotiate with families, patients, physicians and payers.
• High degree of initiative and decision-making skills.

Responsibilities

• Coordinates family and interdisciplinary meetings with all specialties or external agencies to promote movement through the continuum.
• Collaborates with admitting physicians, ED physicians, hospitalists and staff to assist with patient assessment and high-risk screens for resource management.
• Provides consultation for patients with complex psychosocial or continuing care needs and makes referrals to population health teams or external agencies.
• Monitors progress of complex discharge plans with the Care Management team and resolves challenges.
• Facilitates movement to alternate levels of care within the hospital through coordination with patient/family and inter-disciplinary team.
• Attends Care Progression/Rounds and promotes CCM role as an adjunct to clinical care.
• Interacts with coworkers and visitors in alignment with Jefferson values.

Skills

Inpatient care management

Independent work

Interpersonal skills

Decision making

Education

Master’s Degree in Social Work

Job description

Number of Positions In Requisition 1 Job Details

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, 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.

Job Description Summary

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, 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.

Job Duties

• Coordinates family and/or interdisciplinary meetings with all specialties, or external agencies to promote 30% movement through the continuum.
• Collaborates with admitting physician, ED physicians, hospitalists, nursing and other clinical ancillary staff to assist 15% with the patient assessment and high-risk screen for the purpose of resource management.
• 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 referrals to population health teams, payer care coordination teams, or external agencies 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 and ongoing oversight with patient/family, physician, and interdisciplinary team.
• 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.
• Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.

Minimum Qualifications

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

Preferred Qualifications

• Knowledge of Community Agencies required to provide patients and families with appropriate choices and options for post hospital care or prevention of admission.
• Knowledge of guardianship process.
• ACM - Accredited Case Manager - American Case Management Association within 3 Years or CCM - Certified Case Manager - Commission for Case Manager Certification within 3 Years

Physical Demands

Lift and carry 25 lbs. frequent sitting/standing, frequent keyboard use, *patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.

Job Description Disclaimer

This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.

Work Shift

Work Shift Workday Day (United States of America)

Worker Sub Type

Regular Employee Entity Albert Einstein Medical Center Primary Location Address 5501 Old York Road, Philadelphia, Pennsylvania, United States of America Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students.

Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years. Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.

Benefits

• 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

In keeping with Jefferson's Mission, We Improve Lives, it is our goal to recruit, retain, develop and reward highly-qualified employees. If you are enthusiastic, caring and dedicated to service excellence, we invite you to consider joining Jefferson. Jefferson encourages its employees to expand their knowledge and develop their careers through growth opportunities and continuing education. With a long standing history, Jefferson has been advancing the medical field from the heart of Center City Philadelphia for nearly 200 years. Our Mission, We Improve Lives, expands to every corner of the organization. From our weekly farmer’s market, to our new Jefferson Accelerator Zone for innovation, our employees’ passion for the community is evident by the daily gestures towards our patients, students and each other.