Address
Form of workResponsibilities CHW's employed by practice sites via funding from DHS Amendment/Community Based Care Management Program work solely with practice site members who fall into the Top 5% of Health Partners Plan (HPP) members who are categorized as part of this program. The program as such is scheduled to run for a period of no longer than 24 months. ESSENTIAL FUNCTIONS: Assists in the assessment of high risk patients and identifies potential health risks and gaps in non-medical needs such as utilities assistance, food, medications, transportation and other potential needs that can be coordinated using community based resources.
Works with health care team on patients considered to be high risk due to their clinical condition or non-medical needs that may interfere in the management of the plan of care. Inputs relevant, usable data into practice site EHR's for collection by HPP and reporting to DHS on program deliverables. Coordination of behavioral health services with Community Behavioral Health's Community Based Care Management Team.
Supports the plan of care through in-office interviews and discussions as well as using home based visits to foster communication and identification of other health risks such as child and/or adult abuse. Attends appointments with patients to assist in the interpretation of outcomes and needed follow-up activities. Regularly documents all CHW activities in the patients records.
Participates in data collection and reporting activities. Communicates regularly with care team and participates and supports relevant care planning efforts. Works with a social needs referral service to help meet member needs.
Qualifications EDUCATION AND EXPERIENCE REQUIREMENTS: High school graduate or GED Successful completion of CHW training including receipt of certificate and 3 college course hours and completion of appropriate Community Based Care Management program training within specific practice site and HPP (post hire) Completion of appropriate HPP Community Based Care Management Program orientation/training (post hire) Successful completion of CHW training Conditions of Employment Covid Vaccination is a requirement for employment at Jefferson for employees working at Jefferson's clinical entities or at the University. If you are not currently vaccinated you will be required to receive the vaccination prior to hire date if you are offered employment, unless you request and receive an approved medical or religious exemption from Jefferson. Closing Statement Jefferson includes Thomas Jefferson University and Jefferson Health, a dynamic university and health system with broad reach across the Delaware Valley.
Jefferson is the second largest employer in Philadelphia and the largest health system in Philadelphia based on total licensed beds. Through the merger of Thomas Jefferson University and Philadelphia University in 2017, our University includes ten colleges and four schools. We are an NCAA Division II university and an R2 national doctoral university offering undergraduate and graduate-level programs that provide students with a forward-thinking education in architecture, business, design, engineering, fashion and textiles, health, medicine and social science.
Jefferson Health, the clinical arm of Thomas Jefferson University, has grown from a three-hospital academic health center in 2015, to an 18-hospital health system through mergers and combinations that include hospitals at Abington Health, Aria Health, Kennedy Health, Magee Rehabilitation and Einstein Healthcare Network. We have over 50 outpatient and urgent care centers; ten Magnet-designated hospitals (recognized by the ANCC for nursing excellence); the NCI-designated Sidney Kimmel Cancer Center (one of only 70 in the country and one of only two in the region); and one of the largest faculty-based telehealth networks in the country. In 2021, Jefferson Health became the sole owner of HealthPartners Plan, a not-for-profit health maintenance organization in Southeastern Pennsylvania.
We are the first health system regionally to create an aligned payer-provider partnership. Jefferson's mission, vision and values create an organization that attracts the best and the brightest students, faculty, staff, and healthcare professionals, as well as the most visionary leaders to drive exceptional results. OUR MISSION: We improve lives.
OUR VISION: Reimagining health, education and discovery to create unparalleled value OUR VALUES: Put People First, Be Bold & Think Differently and Do the Right Thing As an employer, Jefferson maintains a commitment to provide equal access to employment. Jefferson values diversity and encourages applications from women, members of minority groups, LGBTQ individuals, disabled individuals, and veterans.
