Serves in an expanded clinical role to collaborate with patients, Primary Care Providers, community agencies, behavioral health, and other health plan departments to provide a model of care to maximize member's health status. Integrates evidence-based clinical guidelines, preventive guidelines, protocols, and other metrics in the development of treatment plans that are patient-centric, promoting quality and efficiency in the delivery of healthcare for the Medicaid, Medicare and Commercial populations.
Completes structured clinical assessments for identified patients.
This requires knowledge of medical terminology, diagnostic criteria, and chart review.
Designs an individualized plan of care with the member and fosters a team approach by working collaboratively with the member, family, primary care provider, and other members of the health care team to ensure coordination of services.
Works closely with assigned primary care provider site and functions as a case manager for patients with behavioral health co-morbidities across the care team to develop and maintain positive working relationships with patients, families and providers.
Implements clinical interventions based on risk stratification and evidence-based clinical guidelines in conjunction with the primary care provider or specialist.
Contacts patients through written correspondence and telephone calls, and conducts follow-up interviews.
Provides clinical oversight and guidance to team members.
Participates in data collection, health outcomes reporting, clinical audits and programmatic evaluation related to government initiatives.
In partnership with the care team, identifies patients at risk for poor outcomes or experiencing poor coordination of services who would benefit from more intensive follow up.
Provides chronic disease and self-management education and support.
Conducts in-home member assessments for high risk and complex patient cases.
Develops collaborative relationships with community based agencies to improve care, services and access for Health Plan membership.
Evaluates practices of self and colleagues against standards of practice and relevant regulations and acts to improve compliance.
Maintains required documentation for all case management activities.
Collects required data and utilizes this data to adjust the treatment plan when indicated.
Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.
Master's Degree-Social Work (Required)
Minimum of 2 years-Clinical (Required)
Certification(s) and License(s)
Licensed Social Worker within 1 year - Default Issuing Body
OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence. LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow. INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation. SAFETY: We provide a safe environment for our patients and members and the Geisinger family We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners.* Perhaps just as important, from senior management on down, we encourage an atmosphere of collaboration, cooperation and collegiality. We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
At Geisinger, our innovative ideas are inspired by the communities we serve – like our Fresh FoodFarmacy, a program that delivers life-saving healthy alternatives to patients with diabetes. With additional tools like our MyCode Community Health Initiative, one of the first health system genome sequencingprograms, and our new asthma app suite that we developed in partnership with AstraZeneca, it’s no wonder we’re ranked one of the Top 5 Most Innovative Healthcare Systems by Becker's Hospital Review. We continually work towards continuous improvement in a culture where everyone has a voice and firmly believe that better begins with all of us.Founded more than 100 years ago, Geisinger serves more than three million residents throughout central, south-central and northeastern Pennsylvania and southern New Jersey. Our physician-led system is comprised of 30,000 employees, including 1,600 employed physicians, and consists of 13... hospital campuses, the Geisinger Health Plan, Geisinger Commonwealth School of Medicine and two research centers. What you do at Geisinger shapes the future of health and improves lives – for our patients, communities, and you.