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Housing Focused Care Manager Bsw/msw

3 months ago

Lancaster, United States Lancaster General Health Full time

**Summary**

Penn Medicine Lancaster General Health is seeking a housing focused Ambulatory Care Manager to join our Care Connections team.

This role will bridge three programs serving vulnerable persons experiencing homelessness and hosing insecurity.

**LOCATION**: Lancaster, PA

**HOURS**: Full Time (40 hours per week). Monday-Friday, primarily from 8am-4:30pm but will include some evening outreach work with the Street Medicine Team.

***:
Will provide support to physicians, clinical staff and patients who fall under the auspices of the practice Medical Home Program. Uses an explicit process to identify patients at risk for poor outcomes, and who coordinates care and support, both within and outside of Community Health Services.

**ESSENTIAL FUNCTIONS**: Qualified individuals must have the ability (with or without reasonable accommodation) to perform the following duties:

- In conjunction with the practice team, identify patients at risk for poor outcomes or experiencing poor coordination of services who would benefit from more intensive follow-up.
- Provide proactive outreach to patients to include telephonic, internet or face-to-face encounters.
- Complete a comprehensive assessment of biopsychosocial, cultural and language support and self-management support needs.
- Provide coordination with and act as liaison to hospital, long-term care, specialty, home health services, referrals, screenings and tests for care-managed patients.
- Assist patients in problem-solving potential issues related to the health care system, financial and psychological barriers.
- Be the system navigator and provide direct point of contact access for patient and family questions and concerns.
- Ensure open communication regarding patient interactions with physicians and office staff.
- Arrange referrals, screenings and test procedures.
- Screen and refer as appropriate for depression and other psychological needs.
- Maintain ongoing appropriate documentation on care coordination to promote team awareness, ensure patient safety, and follow through.
- Assume advocate role on patient’s behalf with carriers to ensure approval of necessary supplies/services for patient in a timely fashion.
- Identify and utilize cultural and community resources; establish and maintain relationship with identified service providers.
- Provide medication management, including medication reconciliation and making recommendations to primary care provider for medication changes based on evidence-based protocols.
- Provide chronic disease and self-management education and support.
- Works closely with their assigned primary care practices to offer an individualized assistance with improving and maintaining quality patient care.
- Oversees and guides the development of multiple health partnerships to achieve a positive e health effect.
- Manages rising and high-risk patient, including management of patients with multiple co-morbidities or high risk for readmissions to hospital setting, using a care management platform/analytics.
- Analyzes data to identify under/over utilization; improve resource consumption; promotes potential reduction in cost and enhances quality of care consistent with organization strategic goals and objectives. Data includes but is not limited to predictive analytics, risk stratification, cost-benefit analysis, financial analysis, clinical outcomes; utilization and practice patterns.
- Facilitating transitions and referrals within the LGH health system as well as working with payors to refer appropriately to programs
- Computer skills-utilization of EPIC, Excel, outlook, Microsoft word, intranet, etc.
- Attends periodic educational functions/conferences to enhance program knowledge.
- Job requires travel to patient homes, community settings, multiple practice sites, as well as other locations as needed.

**SECONDARY FUNCTIONS**: The following duties are considered secondary to the primary duties listed above:

- Assesses patient/family needs by coordinating input from all health professionals and formulating a documented plan assuring continuity of care for the rising and high-risk patients.
- Coordinates continuity of patient care with the patients and families following hospital admission, Emergency department(ED) visits, and post discharge.
- Delegates care coordination based on situation while assuming accountability for patient outcome. Supports assistive personnel; serves as a resource and hold assistive personnel accountable to complete delegated tasks.
- In coordianti0on with PCP/Specialists, leads and coordinates activities of interdisciplinary treatment team required to make rising/high risk clinical, benefit and network decisions.
- Identifies appropriate providers, facilities, external healthcare organizations and social agencies/services throughout the continuum of care and communicates with an interdisciplinary treatment team to develop and maintain positive working relationships with patients, families, and provi