Complex Social Worker

Job Details

Job Description

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 (>20 days), 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.

• Collaborates with admitting physicians, ED physicians, hospitalists, nursing and other clinical ancillary staff to assist with the initial patient assessment and high-risk screen for the purpose of resource management.

• Promotes adherence to clinical protocols through collaboration with the physician and interdisciplinary team to encourage evidence-based interventions relevant to the patient's reason for admission and immediate acute care needs.

• Coordinates family and/or interdisciplinary meetings with all specialties to promote movement through the continuum.

• 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 a referral to ambulatory care and payor care coordination resources 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 an ongoing oversight with patient/family, physician, and interdisciplinary team.

• Demonstrates pro-active communication to influence treatment plan and progression of care while advocating on behalf of the patient and organizational stakeholders.

• 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.
• Advanced knowledge of community-based services, state Medicaid waivers, housing programs, and behavioral health systems.
• Deep understanding of legal processes such as guardianship, involuntary commitment, and capacity determinations.
• Ability to de-escalate complex patient/family dynamics and advocate for the most appropriate and ethical care decisions.
• Skill in conflict resolution, motivational interviewing, and trauma-informed care.
• Proficiency in interdisciplinary collaboration, leading family meetings, and navigating payer challenges related to complex discharge planning

Education:

Master's Degree in Social Work

AND

Graduate of an accredited MSW program

Must maintain licensure and certification in good standing throughout employment

Care Management Specialty Certification within 2 years of hire

Experience:

• 3 years Inpatient Care Management experience in an acute care, ambulatory, and/or community-based setting.
• Ability to work independently, setting priorities to coordinate care plans efficiently under constraints of value-based care.
• Knowledge of Community Agencies required to provide patients and families with appropriate choices and options for post hospital care or prevention of admission.
• Interpersonal skills necessary to negotiate with families, patients, physicians and third-party payers for optimum plan.

Work Shift

Worker Sub Type

Primary Location Address

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

At Jefferson, we offer a comprehensive total rewards package designed to support the health and well-being of our colleagues and their families. It includes a wide range of benefits including competitive pay, health and retirement benefits, life and disability insurance, paid time off, educational benefits, financial and mental health resources and much more. Our diverse benefits offerings ensure you have the coverage and access to services you need to thrive both personally and professionally.