Number of Positions In Requisition 1 Job Details Works with minimal supervision to ensure that comprehensive, quality, cost effective patient care is offered for members in need of care coordination. Review medication profiles, verify appropriate testing, and facilitate office visits with primary care and specialist physicians for members targeted for care coordination services. Coordinate with hospital case managers to ensure continuity of care and outpatient services when medically appropriate. Coordinate with behavioral health to ensure continuity of care. Perform outreach, education, and follow-up to members based on criteria determined by Operational Guidelines. Utilize community resources to assist in the coordination of care to maximize positive health outcomes. Assist as needed in the HEDIS data collection project and collaborate with various other members of Health Partners Plans in performing targeted outreach directed at improving outcomes through screenings and preventive health. Job Description Summary Works with minimal supervision to ensure that comprehensive, quality, cost effective patient care is offered for members in need of care coordination. Review medication profiles, verify appropriate testing, and facilitate office visits with primary care and specialist physicians for members targeted for care coordination services. Coordinate with hospital case managers to ensure continuity of care and outpatient services when medically appropriate. Coordinate with behavioral health to ensure continuity of care. Perform outreach, education, and follow-up to members based on criteria determined by Operational Guidelines. Utilize community resources to assist in the coordination of care to maximize positive health outcomes. Assist as needed in the HEDIS data collection project and collaborate with various other members of Health Partners Plans in performing targeted outreach directed at improving outcomes through screenings and preventive health. Job Duties Able to work in a constant state of alertness and safe manner. Conduct timely outreach to members either telephonically or by visiting member in their home for those who have chronic conditions/high utilization and are non-compliant with medications and treatment regimens to improve health outcomes and to include but not limited to: Utilizing appropriate assessments in medical management system; Coordinating care and developing Care Plans for members that are member centric, taking into account the member’s barriers to care and their personal goals. Documentation in medical management system that includes capturing the member’s barriers to care, priority goals, plans of care and schedule for follow up. Educating members concerning their specific health care needs; Researching and coordinating care with available community resources. Researching and coordinating care with member’s behavioral health provider. Informing members about Jefferson Health Plans Medicare benefits. Mailing literature that supports goals and interventions. Coordinate and collaborate care with external as well as internal Jefferson Health Plans resources to meet the individual needs of the member identified by the assessment and subsequent outreach. Assist primary care provider and specialist offices in coordinating care of members. Perform literature searches and follow up to date clinical guidelines in coordinating member care and services. Track assigned cases for timely interventions and trend for disease specific outcomes. Regularly collaborate to evaluate and improve care coordination programs to ensure appropriate medical management. Actively seek guidance from assigned Medical Director or designee as appropriate. Actively participate in multidisciplinary team meetings to represent care coordination program. Function as a liaison for the member internally at Jefferson Health Plans Work collaboratively within the Health Care Management department on tasks as needed. Refer appropriate cases to departments within Jefferson Health Plans to assist with quality of care and utilization management; Actively aware of Corporate and department goals. Other duties as assigned. Minimum Qualifications High School Diploma/GED with LPN License Associate’s Degree in Nursing Master’s Degree in Social Work 2 years case management experience Understanding of Medicare Managed Care delivery systems. Ability to work and communicate effectively with co-workers, members, and providers. Organized, detailed oriented, and capable of handling multiple issues. Excellent telephone and verbal/written communication skills. Computer Literacy and experienced with Microsoft Word, Excel and Outlook. LPN - Licensed Practical Nurse_PA - State of Pennsylvania or RN - Licensed Registered Nurse_PA - State of Pennsylvania or LSW - Licensed Social Worker - State of Pennsylvania Preferred Qualifications Bilingual-Spanish speaking preferred Physical Demands 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. Job Description Disclaimer: 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 responsibilities may be assigned when circumstances require. Work Shift Workday Day (United States of America) Worker Sub Type Regular Employee Entity Health Partners Plans, Inc. Primary Location Address 1101 Market, Philadelphia, Pennsylvania, United States of America Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years. Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status. Benefits Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance. For more benefits information, please click here In keeping with Jefferson's Mission, We Improve Lives, it is our goal to recruit, retain, develop and reward highly-qualified employees. If you are enthusiastic, caring and dedicated to service excellence, we invite you to consider joining Jefferson. Jefferson encourages its employees to expand their knowledge and develop their careers through growth opportunities and continuing education. With a long standing history, Jefferson has been advancing the medical field from the heart of Center City Philadelphia for nearly 200 years. Our Mission, We Improve Lives, expands to every corner of the organization. From our weekly farmer’s market, to our new Jefferson Accelerator Zone for innovation, our employees’ passion for the community is evident by the daily gestures towards our patients, students and each other.

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