Care Manager - Community Liaison - Outreach

Summary The Care Manager / Community Liaison – Outreach provides care management, resource coordination, and community engagement services to vulnerable older adults throughout Greater Philadelphia. Working as part of an interdisciplinary team, this position helps clients and caregivers access community resources, benefits, health care, and supportive services that promote safety, stability, independence, and the ability to age in place. This position supports JFCS' commitment to strengthening individuals, families, and communities by connecting older adults and caregivers with compassionate, culturally responsive, and practical supports. In addition, the Care Manager serves as a community outreach liaison, building and maintaining strong relationships with community organizations, healthcare providers, senior-serving agencies, and other referral partners. The Care Manager participates in outreach, education, and engagement activities that increase awareness of available services, strengthen community partnerships, identify individuals who may benefit from support, and contribute to program growth. The Care Manager / Community Liaison – Outreach uses a person-centered, strengths-based, and trauma-informed approach and collaborates with clients, caregivers, health care providers, community partners, and internal teams to address client needs. Services are delivered through a hybrid model that may include in-home visits, office-based services, community outreach, and remote work. Responsibilities Conduct comprehensive client assessments to identify cognitive, medical, functional, behavioral, and social support needs. Develop, implement, maintain, and update individualized electronic records and care plans in collaboration with clients, caregivers, and the interdisciplinary care team. Maintain timely and complete documentation of client interactions, care plans, assessments, progress notes, and billable services within the electronic health record (EHR). Perform caregiver assessments to identify caregiver needs, provide education, and connect clients and families with appropriate community resources and support services. Provide ongoing care management services for clients in accordance with CMS guidelines. Advocate for clients by helping them navigate the healthcare system and access appropriate medical, behavioral health, and community services. Conduct routine client outreach to monitor health status, medication adherence, treatment compliance, and progress toward care plan goals. Identify barriers to care and develop interventions to improve patient engagement, self-management, and health outcomes. Facilitate communication among clients, caregivers, and other members of the care team to ensure continuity of care. Track and document care management time to support CMS billing and reimbursement requirements. Ensure compliance with CMS GUIDE, CCM, HIPAA, Medicare documentation standards, and applicable organizational policies and procedures. Monitor quality measures and contribute to initiatives that improve client outcomes, patient satisfaction, and program performance. Develop and maintain positive working relationships with community organizations, healthcare providers, senior centers, social service agencies, faith-based organizations, and other community partners to strengthen referral networks and access to services. Represent JFCS and the care management program at community events, health fairs, senior programs, educational presentations, provider meetings, and other outreach activities. Engage in proactive community outreach to educate older adults, caregivers, professionals, and community organizations about available JFCS programs, care management services, and community resources. Identify potential clients and referral opportunities through community outreach and establish connections with the care management team and intake/referral processes. Coordinate with internal programs and external community partners to facilitate referrals, promote continuity of services, and address gaps in resources for older adults and their caregivers. Provide presentations and educational materials on care management, aging-related services, benefits, healthcare navigation, and other relevant topics to community and professional audiences. Track and report community outreach activities, referral sources, partnership development, and other program engagement metrics as assigned. Identify emerging community needs, service gaps, and barriers affecting older adults and communicate findings to leadership to support program development, growth, and continuous improvement. Participate in team conferences, trainings, weekly supervision, department meetings, and other staff meetings as assigned. Perform other duties as assigned by the direct supervisor. Competencies Knowledge of public benefits, entitlement programs, and community resources serving older adults and caregivers. Demonstrates knowledge of Centers for Medicare & Medicaid Services (CMS) regulations, compliance standards, and person‑centered care requirements, and applies them consistently in service delivery and documentation. Strong written and verbal communication skills with internal and external stakeholders. Strong interpersonal and relationship-building skills with the ability to establish and maintain effective partnerships with community organizations and referral sources. Ability to conduct community presentations, outreach activities, and educational sessions for diverse audiences. Must be able to maintain strict confidentiality and handle protected health information (PHI) in compliance with HIPAA regulations. Ability to manage multiple priorities and work independently with follow‑through. Professional demeanor and ability to work effectively with a diverse client population and community partners. Ability to work as a team member with other clinicians and care managers to ensure best service to clients. Sound judgment in situations where procedures may not be fully standardized. Strong collaboration and teamwork skills across internal and external partners. Demonstrate initiative in contributing to the development of the department's programs, community partnerships, and services, as well as their own professional development. Flexibility and adaptability in response to changing schedules, community needs, outreach activities, and program requirements. Requirements Bachelor's degree in social services, human services, health care, or a related field required; Master's degree preferred. Minimum of two (2) years of experience in care management, case management, chronic disease management, population health, or a related healthcare setting. Experience working with older adults. Experience developing relationships with community organizations, healthcare providers, referral sources, or other external partners preferred. Experience conducting community outreach, presentations, education, or engagement activities preferred. Excellent communication, organizational, relationship-building, and critical thinking skills. Ability to work independently while collaborating effectively with interdisciplinary teams and community partners. Proficiency with Electronic Health Records (EHR) and Microsoft Office applications. Other Requirements Successful completion of criminal background check, child abuse clearance, and FBI fingerprinting. Ability to work at multiple JFCS locations, in client homes, and in community settings. Driving is required for assigned duties; the employee must maintain a valid driver's license, proof of insurance, and a safe driving record.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. The employee may be required to sit, stand, walk, travel to client homes and community locations, use a computer and phone, and communicate effectively with clients, caregivers, colleagues, and community partners. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EQUAL EMPLOYMENT OPPORTUNITY

JFCS is an equal opportunity employer and is committed to creating an inclusive environment for all employees. JFCS does not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity or expression, national origin, age, disability, veteran status, or any other characteristic protected by applicable law. #J-18808-Ljbffr Jewish Family and Children's Service of Greater Philadelphia