Job Summary:

The incumbent is a member of an interdisciplinary team and is responsible for ongoing intervention and support for patient care and clinical initiatives. The Medical Case Manager (MCM) is responsible for enhancing the delivery of primary health care through psychosocial assessment, resource and benefit coordination, case management services for targeted individuals and populations, and care coordination support.

This position will be based at our Spectrum Community Health Center in West Philadelphia and will serve a population of pediatric and adult patients in a primary care office setting with occasional women’s health/obstetrics cross-coverage.

Care Competencies:

• Interpersonal skills and communication
• Medical Knowledge
• Systems based practice
• Practice Based learning and improvement
• Patient Care and Professionalism
• Cultural humility

Essential Functions:

• Conducts psychosocial assessments and social determinant of health screenings and responds to referrals from providers and other Spectrum staff
• Provides comprehensive patient education on and resource referrals for identified social determinant of health and other psychosocial needs including financial/food/housing/transportation insecurity, interpersonal violence, immigration concerns, and educational needs
• Assists patients in understanding their diagnoses, treatment options, and resources available to them. Provides support for advanced care planning
• Troubleshoots barriers to adhering to plan of care
• Meets with patients in office to identify patient needs/concerns and making warm/lukewarm handoffs to internal and external resources
• Conducts phone outreach and follow-up to referred/identified patients
• Conducts transitions of care outreach to patients recently discharged from the ED or hospital
• Provides longitudinal follow-up support to target patients and populations per the needs of the care management program
• Assists with referrals to skilled home care services and home health aides
• Navigates health and systems literacy barriers to assist patients in effectively obtaining needed health care and other services inside and outside of Spectrum
• Coordinates with financial counselors to assist uninsured patients in applying for health insurance, emergency medical assistance, and emergency medication coverage.
• Assists with medication access matters and coordination with the 340b pharmacy and program manager
• Provides individual and family support and referral as necessary to resolve emotional and psychosocial problems.
• Documents all patient contacts, case updates and referrals in the medical record according to established protocols and standards.
• Audits medical record outcomes related to area of expertise.
• Prepares reports and audits requested by the supervisor.
• Builds relationships with community resources external to Spectrum.
• Coordinates organizational outreach and education activities to include community presentations and participation in health fairs as required.
• Serves on special committees and performs other duties as assigned.

Supervisory Functions:

N/A
Experience and Skills:

Minimum Qualifications and Experience:

• Bachelor’s degree in Social Work, Sociology, Anthropology, Psychology, Ethnic Studies, other Social Science, or related field preferred
• At least one (1) year experience in case management or clinical experience in ambulatory healthcare preferred
• Professional or volunteer experience working with a multicultural patient/client population
• Basic knowledge of public benefits and community resources in the Philadelphia area (especially Haddington, Mill Creek, and other West Philadelphia neighborhoods) preferred
• Experience working with pediatric patients/clients and their caregivers preferred
• Knowledge of Microsoft Office applications including Word, Outlook, Teams and Excel required
• Knowledge in accessing and using the Internet required
• Automobile and current driver license preferred but not required
• Ability to be flexible and work at all center locations as required.

Benefits:

A comprehensive healthcare package will be presented at offer
From: Spectrum Health Services, Inc