Complex Care Manager: Discharge & Care Coordination

Jefferson Health; Philadelphia (Philadelphia County); On-site; USD 75,000 - 110,000; Full time

Job summary

Jefferson Health is seeking a Complex Care Manager in Philadelphia to serve as a regional liaison, leading care plan execution for patients with complex psychosocial needs. The role activates for challenging cases requiring advanced discharge planning, guardianship, or coordination with state and local agencies.

You will drive interdisciplinary collaboration, coordinate with physicians and care teams, and ensure safe, ethical transitions across the care continuum.

Qualifications

• Master’s Degree in Social Work required.
• 3 years inpatient care management in an acute care setting.
• Ability to work independently and manage priorities.
• Strong interpersonal and negotiation skills.
• Experience coordinating with families, physicians, and payers.

Responsibilities

• Coordinates family and interdisciplinary meetings to promote movement through the continuum.
• Collaborates with admitting, ED, hospitalists, nursing and other clinical staff to assist with patient assessment and high-risk screening for resource management.
• Provides consultation for complex psychosocial needs and makes referrals to related teams when appropriate.
• Monitors progress of complex discharge plans and collaborates to resolve challenges with the team.
• Facilitates patient movement to alternate levels of care within the hospital through coordination with patient/family and the interdisciplinary team.
• Attends Care Progression Rounds and Complex Care Rounds to promote CCM role within the team.

Skills

Care management

Independent work

Interpersonal skills

Negotiation skills

Education

Master’s Degree in Social Work

Job description

Jefferson Health is seeking a Complex Care Manager in Philadelphia to serve as a regional liaison, leading care plan execution for patients with complex psychosocial needs. The role activates for challenging cases requiring advanced discharge planning, guardianship, or coordination with state and local agencies.

You will drive interdisciplinary collaboration, coordinate with physicians and care teams, and ensure safe, ethical transitions across the care continuum.