Social Worker Ambulatory Care Manager (Full Time/Days)

Description Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines. Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work? LOCATION: Gap/Chester Region - Parkesburg, PA HOURS: Full Time (40 hours per week). Monday-Friday (8am-4:30pm). No weekends or holidays. The Ambulatory Case Manager will provide support to physicians, clinical staff and patients who fall under the auspices of the practice Medical Home Program. Using 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

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. As RN primary role of regional team will lead in 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. Minimum Required Qualifications An RN or Social Worker is required for this role, with specific requirements being one of the following: RN: 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 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 Additional Minimum Requirements 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. Experience with mental health clients/patients Bilingual proficiency in Spanish We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives. Live Your Life's Work We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law. #J-18808-Ljbffr Penn Medicine, University of Pennsylvania Health System