Housing Focused Care Manager Bsw/Msw (Full Time/Days)

Summary

Penn Medicine Lancaster General Health is seeking a housing focused Ambulatory Care Manager to join our Care Connections team.

This role will bridge three programs serving vulnerable persons experiencing homelessness and housing insecurity.

Job Description

LOCATION: Lancaster, PA

HOURS: Full Time (40 hours per week). Monday-Friday, primarily from 8am-4:30pm but will include some evening outreach work with the Street Medicine Team.

POSITION SUMMARY:

Will provide support to physicians, clinical staff and patients who fall under the auspices of the practice Medical Home Program. Uses an explicit process to identify patients at risk for poor outcomes, and who coordinates care and support, both within and outside of Community Health Services.

ESSENTIAL FUNCTIONS: Qualified individuals must have the ability (with or without reasonable accommodation) to perform the following duties:

• In conjunction with the practice team, identify patients at risk for poor outcomes or experiencing poor coordination of services who would benefit from more intensive follow-up.

• Provide proactive outreach to patients to include telephonic, internet or face-to-face encounters.

• Complete a comprehensive assessment of biopsychosocial, cultural and language support and self-management support needs.

• Provide coordination with and act as liaison to hospital, long-term care, specialty, home health services, referrals, screenings and tests for care-managed patients.

• Assist patients in problem-solving potential issues related to the health care system, financial and psychological barriers.

• Be the system navigator and provide direct point of contact access for patient and family questions and concerns.

• Ensure open communication regarding patient interactions with physicians and office staff.

• Arrange referrals, screenings and test procedures.

• Screen and refer as appropriate for depression and other psychological needs.

• Maintain ongoing appropriate documentation on care coordination to promote team awareness, ensure patient safety, and follow through.

• Assume advocate role on patient's behalf with carriers to ensure approval of necessary supplies/services for patient in a timely fashion.

• Identify and utilize cultural and community resources; establish and maintain relationship with identified service providers.

• Provide medication management, including medication reconciliation and making recommendations to primary care provider for medication changes based on evidence-based protocols.

• Provide chronic disease and self-management education and support.

• Works closely with their assigned primary care practices to offer an individualized assistance with improving and maintaining quality patient care.

• Oversees and guides the development of multiple health partnerships to achieve a positive e health effect.

• Manages rising and high-risk patient, including management of patients with multiple co-morbidities or high risk for readmissions to hospital setting, using a care management platform/analytics.

• Analyzes data to identify under/over utilization; improve resource consumption; promotes potential reduction in cost and enhances quality of care consistent with organization strategic goals and objectives. Data includes but is not limited to predictive analytics, risk stratification, cost-benefit analysis, financial analysis, clinical outcomes; utilization and practice patterns.

• Facilitating transitions and referrals within the LGH health system as well as working with payors to refer appropriately to programs

• Computer skills-utilization of EPIC, Excel, outlook, Microsoft word , intranet, etc.

• Attends periodic educational functions/conferences to enhance program knowledge.

• Job requires travel to patient homes, community settings, multiple practice sites, as well as other locations as needed.

SECONDARY FUNCTIONS: The following duties are considered secondary to the primary duties listed above:

• Assesses patient/family needs by coordinating input from all health professionals and formulating a documented plan assuring continuity of care for the rising and high-risk patients.

• Coordinates continuity of patient care with the patients and families following hospital admission, Emergency department(ED) visits, and post discharge.

• Delegates care coordination based on situation while assuming accountability for patient outcome. Supports assistive personnel; serves as a resource and hold assistive personnel accountable to complete delegated tasks.

• In coordianti0on with PCP/Specialists, leads and coordinates activities of interdisciplinary treatment team required to make rising/high risk clinical, benefit and network decisions.

• Identifies appropriate providers, facilities, external healthcare organizations and social agencies/services throughout the continuum of care and communicates with an interdisciplinary treatment team to develop and maintain positive working relationships with patients, families, and providers.

• Functions as a coordinator and manager of a defined health population across care setting and for multiple physicians/health care providers or health plan counterparts.

• Works together with other staff members on projects, determining scope, timeline for implementation and outcomes.

• Works as a team member with emphasis on ensuring internal/external customer needs met.

• Participate in supporting quality improvement implementation of new forms, processes and procedures.

• Participates in orientation and education of individuals to the functions of this position.

• Joint role, along with Social Work of triaging of incoming (New) referrals to ACC department.

• Other duties as assigned.

JOB REQUIREMENTS

MINIMUM REQUIRED QUALIFICATIONS:

RN or Social Worker is required for this role, with specific requirements being one of the following:

Registered Nurse:

• Current licensure as a Registered Nurse, issued by the Pennsylvania Board of Nursing.

• Bachelor's degree in Nursing (BSN) or a related health care degree is required OR RN with at least ten (10) years acute/subacute care or CM experience.

Social Worker:

• Master's degree in Social Work (MSW)
• OR a Bachelor's degree in Social Work (BSW) with a Master's degree (MS) in Human Services from an accredited school or program
• OR Bachelor's degree in Social Work with ten (10) years relevant experience.

Other Requirements include:

• Three (3) years of acute care nursing or social work experience.

• Excellent verbal and written communication skills.

• Excellent Customer service skills.

• Proven informal leadership skills.

• Ability to work independently, setting priorities to coordinate care plans efficiently.

• Ability to work effectively in a fast-paced team environment.

• Highly organized and detail-oriented with the ability to perform multiple tasks simultaneously.

• Effective behavioral and educational strategies, including, but not limited to: Motivational interviewing, teach-back method and self-management support.

• Must have valid driver's license and daily access to an insured vehicle.

PREFERRED QUALIFICATIONS:

• Knowledge of Utilization review or managed care

• Licensure with Commission for Case Managers (CCM), or expected to obtain within two (2) years of employment.

Disclaimer: This job description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills, efforts, or working conditions associated with the job. It is intended to be a reflection of those principal job elements essential for recruitment and selection, for making fair job evaluations, and for establishing performance standards. The percentages of time spent performing job duties are estimates, and should not be considered absolute. The incumbent shall perform all other functions and/or be cross-trained as shall be determined at the sole discretion of management, who has the right to amend, modify, or terminate this job in part or in whole. Incumbent must be able to perform all job functions safely. #LI-LJ1

Benefits At A Glance:

PENN MEDICINE LANCASTER GENERAL HEALTH offers the following benefits to employees:

• 100% Tuition Assistance at The Pennsylvania College of Health Sciences

• Paid Time Off and Paid Holidays

• Shift, Weekend and On-Call Differentials

• Health, Dental and Vision Coverage

• Short-Term and Long-Term Disability

• Retirement Savings Account with Company Matching

• Child Care Subsidies

• Onsite Gym and Fitness Classes

Disclaimer

PENN MEDICINE LANCASTER GENERAL HEALTH is an Equal Opportunity Employer, committed to hiring a diverse workforce. All openings will be filled based on qualifications without regard to race, color, sex, sexual orientation, gender identity, national origin, marital status, veteran status, disability, age, religion or any other classification protected by law.

Search Firm Representatives please read carefully: PENN MEDICINE LANCASTER GENERAL HEALTH is not seeking assistance or accepting unsolicited resumes from search firms for this employment opportunity. Regardless of past practice, all resumes submitted by search firms to any employee at PENN MEDICINE LANCASTER GENERAL HEALTH via-email, the Internet or directly to hiring managers at Penn Medicine Lancaster General Health in any form without a valid written search agreement in place for that position will be deemed the sole property of PENN MEDICINE LANCASTER GENERAL HEALTH, and no fee will be paid in the event the candidate is hired by PENN MEDICINE LANCASTER GENERAL HEALTH as a result of the referral or through other means.