Complex Care Manager (Full-Time​/Day) Hybrid​/Stratford

Job Details

Serves as a regional liaison to the Care Management Department and, when necessary, assumes the primary Care Manager's role. This role is activated for complex patients requiring advanced discharge planning support due to barriers such as extended hospital stays, guardianship or legal interventions, behavioral health comorbidities, homelessness, substance use disorders, or medically complex conditions requiring coordination with state and local agencies.

The Complex Care Manager drives interdisciplinary collaboration and leads care plan execution for patients with highly challenging psychosocial needs, ensuring safe, ethical, and timely transitions across the care continuum.

Monday - Friday (8 am - 4:30 pm) Hybrid Schedule No weekends, no holidays or on-call NJ LICENSE IS REQUIRED MSW IS REQUIRED

Serves as a regional liaison to the Care Management Department and, when necessary, assumes the primary Care Manager's role. This role is activated for complex patients requiring advanced discharge planning support due to barriers such as extended hospital stays, guardianship or legal interventions, behavioral health comorbidities, homelessness, substance use disorders, or medically complex conditions requiring coordination with state and local agencies.

The Complex Care Manager drives interdisciplinary collaboration and leads care plan execution for patients with highly challenging psychosocial needs, ensuring safe, ethical, and timely transitions across the care continuum.

• Coordinates family and/or interdisciplinary meetings with all specialties, or external agencies to promote 30% movement through the continuum.
• Collaborates with admitting physician, ED physicians, hospitalists, nursing and other clinical ancillary staff to assist 15% with the patient assessment and high-risk screen for the purpose of resource management.
• Provides consultation for patient/families with complex psychosocial or continuing care needs that may present obstacles for a safe transition to a lower level of care or discharge to the community and makes referrals to population health teams, payer care coordination teams, or external agencies when appropriate.
• Works collaboratively with the IPT Care Management team to monitor the progress of completing complex discharge plans and collaborates to resolve challenges.
• Facilitates patient movement to alternate levels of care within the hospital through coordination and ongoing oversight with patient/family, physician, and interdisciplinary team.
• Attends assigned Care Progression Rounds, Complex Care Rounds or specific patient meetings and promotes CCM role as an adjunct to the team’s clinical expertise.
• Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.

• Master’s Degree in Social Work
• 3 years Inpatient Care Management experience in an acute care setting
• Ability to work independently, setting priorities to coordinate care plans efficiently under constraints of value-based care.
• Interpersonal skills necessary to negotiate with families, patients, physicians and third-party payers for optimum plan.
• High degree of initiative and decision making skills

• Knowledge of Community Agencies required to provide patients and families with appropriate choices and options for post hospital care or prevention of admission.
• Knowledge of guardianship process.
• ACM
  - Accredited Case Manager
  - American Case Management Association within 3 Years
• CCM
  - Certified Case Manager
  - Commission for Case Manager Certification within 3 Years

Lift and carry 25 lbs. frequent sitting/standing, frequent keyboard use,
* patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.

This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other…