Equal Opportunity Employer
The mission of the Health Federation of Philadelphia is to promote health equity for marginalized communities by advancing access to high-quality, integrated, and comprehensive health and human services. Health equity is at the heart of all our work. We believe in and are firmly committed to equal employment opportunity for employees and applicants. We do not discriminate on the basis of race, color, national or ethnic origin, ancestry, age, religion, disability, sex or gender, gender identity and/or expression, sexual orientation, military or veteran status. This commitment applies to all aspects of the Health Federation of Philadelphia’s employment practices, including recruiting, hiring, training, and promotion.
Health Federation of Philadelphia has a care management program in collaboration with six health centers and a Medicaid managed care plan aimed at reducing health inequities, addressing social determinants of health, and improving health outcomes for low-income patients struggling with chronic physical and mental health conditions. We are seeking an experienced Care Coordinator who is familiar with the pace of, and populations served by, community-based health care providers in Philadelphia.
This position will be part of a team of four, including the Team Manager and two Community Health Workers who will work with six community health centers and a Medicaid Managed Care Organization (MCO) to achieve improved outcomes for health center patients enrolled with the MCO and attributed to one of the health centers. The team works to assess needs of identified patients at high risk of poor health outcomes, and to engage these individuals in primary care and other services, with the goals of improving health status and reducing hospitalizations, as well as to address quality metrics and “care gaps”. The Care Management Team will engage patients who are not receiving regular care at their assigned primary care location and follow-up with individuals with recent hospital contact (inpatient and/or Emergency Department).
As the primary clinical skilled on the team, the Care Coordinator is responsible for managing vulnerable patients to promote effective education, self-management support and timely healthcare delivery, with the goal of achieving optimal quality and financial outcomes. This position is hybrid with 40% remote work and the remainder 60% working between the office and community.
- Effectively engage identified individuals in Care Management services, using telephonic and in-person outreach.
- Perform initial and periodic holistic assessments for care managed population. Prioritize patients according to intensity, need, and required follow up.
- Perform medication management reviews, including reconciling discharge medications with ongoing medication regimens and develop a patient-directed self-management strategy for compliance.
- Perform follow up calls for patients recently discharged from acute hospitalizations and who are considered to be high risk for readmission. As needed, perform hospital visits and/or home visits.
- Collaborate with health center based providers, inpatient facilities, the Medicaid MCO, and skilled nursing facilities to manage care across the healthcare continuum and optimize clinical and financial outcomes.
- Determine and complete appropriate service referrals. Serves as a liaison to providers, patients and families for coordination of services.
- Linking patients to social services programs and entitlements such as transportation assistance and translation services.
- Conducting regular follow-ups with patients to evaluate progress, promote continuity of care, and ensure improved health outcomes.
- Work collaboratively with the Medicaid MCO team for clinical consultation, mobilization of resources, and effective documentation of care for appropriate payment.
- Maintain accurate and timely documentation.
- Maintain constant communication with health center care teams to insure that all members of the patients’ healthcare team are informed and duplication of effort is avoided.
Graduate from an accredited nursing program
- At least 1 years of experience in a clinical role, with a focus on vulnerable individuals struggling with chronic physical and/or mental health conditions.
- Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.
- Demonstrates ability to work autonomously and be directly accountable for practice.
- Demonstrates ability to function effectively in a fluid, dynamic and rapidly changing environment.
- Demonstrates leadership qualities including time management, verbal and written communication skills, listening skills, problem solving, critical thinking, analysis skills and decision-making, priority setting, work delegation, and work organization.
- Demonstrates ability to develop positive, longitudinal relationships and set appropriate boundaries with patients/families.
- Demonstrates excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills.
- Adept with technology and data, including electronic health records, payer portals, Microsoft office, and Google apps.
- Understands the workflows and challenges of busy primary care offices.
- Ability to travel locally
- Community health center and/or Medicaid program experience a plus.
- Ability to work with patients in language other than English (especially Spanish).
Position Type and Work Schedule
This is a full-time, exempt position.
Standard office setting, plus regularly scheduled meetings, trainings, etc. with participating health centers, occasional home or hospital visits.
Able to sit and work at a computer keyboard for extended periods of time. Able to lift and move up to 15 pounds.
Must be able to get around effectively within Philadelphia and surrounding counties, either on public transportation and/or in own vehicle. Limited travel beyond surrounding counties will be required, as well.
Salary and Benefits
$52-60k annually depending on experience and qualifications
Our employees are our most valuable resource, so we offer a competitive and comprehensive benefits package, which can include:
- Medical with vision benefits
- Dental insurance
- Flexible spending accounts
- Life, AD&D and long term care insurance
- Short- and long-term disability insurance
- 403(b) Retirement plan, with a company contribution
- Paid time off, including vacation, sick, personal and holiday
- Employee Assistance Program
Eligibility and participation is handled consistent with the plan documents and HFP policy.
The Health Federation reserves the right to modify, interpret, or apply this job description in any way the Company desires. The above statements are intended to describe the general nature and level of work being performed by an employee assigned to this position. This job description in no way implies that these are the only duties, including essential duties, responsibilities and/or skills to be performed by the employee occupying this position. This job description is not an employment contract, implied, or otherwise. The employment relationship remains “at will.” The aforementioned job requirements are subject to change to reasonably accommodate qualified disabled individuals.