Social Worker

PRIMARY RESPONSIBILITY:

The Social Worker will facilitate patient continuity of care throughout the healthcare system. S/he collaborates with the Primary Care team to provide leadership in issues of outcomes management, disease management and prevention, and development of improved strategies to benefit high risk patients. This role will engage patients and encourage them to take an active role in their health by providing them with the tools necessary to make healthy lifestyle choices and adopt life-long healthy behaviors. This role will serve as an advisor to the clinical team for health and human services resources as well as guardianship and behavioral health issues. Functions as an advocate for the patient where applicable, and work collaboratively with internal/external resources to ensure the needs of our patients are consistently met

ESSENTIAL FUNCTIONS:

1. Compiles and discusses findings with support team to evaluate and manage geriatric conditions in the home.

2. Performs psychosocial assessments that will identify applicable barriers, problems, goals, and interventions that will close gaps in care and address those needs and improve or maintain the health status of the patient, based on assessment of patient’s needs and environment

3. Engages and counsels patient and family members to develop an individualized plan of care to promote healthy lifestyles, close gaps in care, and reduce unnecessary ER utilization and hospital readmissions. Develops and coordinate the individualized plan of care with the member, member’s family, providers and community agencies as applicable. Involves other staff to support the individualized plan of care based on identified needs of the patient

4. Follow-ups with the patient according to established clinical program protocols and timeframes to monitor their status, evaluate the effectiveness of the individualized plan of care, and identify new needs. Modifies the individualized plan of care or case status based on the status of the patient.

5. Documents activities in a timely and accurate manner; assuring all documentation complies with Jefferson’s quality standards, CMS standards, DVACO standards, etc.

CERTIFICATES, LICENSES, AND REGISTRATION:

Masters in social work required.

EXPERIENCE REQUIREMENTS:

• 5 years experience in hospital or community clinic, home care, discharge planning, and/or case management required
• 3 years experience in a managed care environment preferred
• Minimum 2 years experience working with frail or elderly population
• Strong behavioral health background
• Ability to interact with physicians and other health care professional in a professional manner required
• Computer proficiency required
• Excellent verbal and written communication and interpersonal skills required
• Ability to prioritize daily tasks and caseload activities to meet patient needs and turnaround times
• Knowledge of managed care models, financial reimbursement systems, clinical case management processes, and utilization management issues
• Knowledge of NCQA (PCMH) guidelines for care coordination

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.

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.

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.