Acute Care, Complex Care Manager- MSW

Job Details

Job Description

Essential Functions
Interacts with co-workers visitors and other staff consistent with the values of Jefferson.
Collaborates with admitting physicians ED physicians hospitalists nursing and other clinicalancillary staff to assist with the initial patient assessment and high-risk screen for the purpose ofresource management.
Promotes adherence to clinical protocols through collaboration with the physician andinterdisciplinary team to encourage evidence-based interventions relevant to the patients reasonfor admission and immediate acute care needs.
Coordinates family and/or interdisciplinary meetings with all specialties to promote movementthrough the continuum.
Provides consultation for patient/families with complex psychosocial or continuing care needs thatmay present obstacles for a safe transition to a lower level of care or discharge to the communityand makes a referral to ambulatory care and payor care coordination resources when appropriate.
Works collaboratively with the IPT Care Management team to monitor the progress of completingcomplex discharge plans and collaborates to resolve challenges.
Facilitates patient movement to alternate levels of care within the hospital through coordination anongoing oversight with patient/family physician and interdisciplinary team.
Demonstrates pro-active communication to influence treatment plan and progression of care whileadvocating on behalf of the patient and organizational stakeholders.
Attends assigned Care Progression Rounds Complex Care Rounds or specific patient meetings andpromotes CCM role as an adjunct to the teams clinical expertise.
Other duties as assigned

Competencies (Knowledge Skills and Abilities Required):
Communicates Effectively
Customer Focus
Situational Adaptability
Values differences
Advanced knowledge of community-based services state Medicaid waivers housingprograms and behavioral health systems.
Deep understanding of legal processes such as guardianship involuntary commitment andcapacity determinations.
Ability to de-escalate complex patient/family dynamics and advocate for the mostappropriate and ethical care decisions.
Skill in conflict resolution motivational interviewing and trauma-informed care.
Proficiency in interdisciplinary collaboration leading family meetings and navigating payer
challenges related to complex discharge planning

Minimum Education and Experience Requirements:
Education:
Masters Degree in Social Work
AND
Experience:
3 years Inpatient Care Management experience in an acute care ambulatory and/orcommunity-based setting.
Ability to work independently setting priorities to coordinate care plans efficiently underconstraints of value-based care.
Knowledge of Community Agencies required to provide patients and families withappropriate choices and options for post hospital care or prevention of admission.
Interpersonal skills necessary to negotiate with families patients physicians and third-partypayers for optimum plan.

Minimum Certifications Registration or License Requirements:
Graduate of an accredited MSW program
Must maintain licensure and certification in good standing throughout employment
Care Management Specialty Certification within 2 years of hire

Additional Information
Excellent verbal and written communication skills. High degree of initiative and independent decisionmaking. Ability to establish and sustain a positive impact at all levels of the organization.

Strong working knowledge of community-based behavioral health systems and complex dischargeprotocols
Proficient in navigating payer systems and advocating for coverage of non-traditional discharge needs(e.g. long-term acute care behavioral health placement homelessness)
Demonstrated ability to coordinate with legal services guardianship court and local/state agencies for atrisk patient populations.
High level of emotional intelligence problem-solving and resilience in high-stress ethically complexsituations
Experience using electronic medical records and documentation systems (e.g. Epic)
Comfortable working independently and as part of an interdisciplinary team to lead and resolve complexcare barriers
Excellent verbal and written communication skills. High degree of initiative and independent decisionmaking. Ability to establish and sustain a positive impact at all levels of the organization

Work Shift

Worker Sub Type

Employee Entity

Primary Location Address

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 65000 people strong dedicated to providing the highest-quality compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrows 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 8300 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

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 diemcolleagues adjunct faculty and Jeff Temps) have access to medical (including prescription) insurance.

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