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Form of workResponsibilities Job Description The Community Based Case Management (CBCM) interdisciplinary field-based teams are comprised of nurse navigators or Social Workers, community health workers, and/or patient navigators. The teams are embedded in high volume practices and serve members with high medical and or social needs. These teams provide clinical education, as well as linkages to clinical, social determinants of health, and behavioral health resources in an effort to offer holistic care to members with the goal of improving sustainable health outcomes.
Additionally, the teams work closely with counterparts from the BH-MCO and collaborate to complete Integrated Care Plans for eligible members. The interdisciplinary field-based teams are on-site at provider officers, which allows for face-to-face engagement. Telemedicine and telehealth are utilized to engage and follow-up with members when appropriate.
Home and community visits are completed as needed. The Social Worker assesses needs of members, assists member in identifying health goals, provides education on chronic conditions, and completes referrals to appropriate resources. Social Worker Job Responsibilities General Responsibilities The Social Worker works collaboratively with multidisciplinary care teams including site staff, CBCM program staff, CBH, CHWs, HPP Pharmacy, and HPP Care Management staff.
The Social Worker provides site and community-based support and guidance to HPP Medicaid members at the site who need clinical and non-clinical resources. The Social Worker promotes positive behavior change; assists with addressing health issues; and identifies both medical and non-medical needs of members. The Social Worker conducts clinical education, support and training based on guidance from the site clinical care team on diseases such as diabetes, COPD, HTN, etc.
The Social Worker collects and provides required data to CBCM team for reporting to DHS. Qualifications Education: MSW (LSW preferred with a minimum of two years of case management experience) Experience: 3-5 years of care/case management experience Experience in an ambulatory care environment Clinical experience with pediatric populations Experience working with Medicaid or other similar populations. Skills/Abilities: Dependability, consistency, and professionalism Working knowledge of care/case management standards, community resources, medical terminology, treatment modalities, special needs population, and related Federal/State regulations Demonstrated resourcefulness with locating and utilizing community-based resources for the Medicaid population- especially including the pediatric/special needs population Excellent communication, interpersonal, organizational and time management skills Ability to cultivate and sustain relationships with internal and external teams Strong attention to detail; self-motivated Ability to problem-solve as part of a care team Ability to give and receive supervision and performance feedback Ability to coach care team colleagues Ability to work flexibly to meet the needs of members, the care team and practice site Sensitivity to unique/non-traditional life circumstances 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. Conditions of Employment Since this position will require the selected candidate to engage in regular contact with children in the form of care, guidance, supervision or training, you will be required to meet the requirements of the Child Protective Services Act, including the Pennsylvania State Police criminal background check, the Pennsylvania Department of Welfare child abuse criminal background clearance, and an FBI finger print based federal criminal records check. The selected candidate will not be allowed to commence working until all three (3) are completed satisfactorily.
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.
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