Discharge & Complex Care Navigator

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

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.