• Main Line Health
  • $50,560.00 -78,130.00/year*
  • Philadelphia , PA
  • Advertising/Marketing/Public Relations
  • Full-Time
  • 1103 Market St

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Main Line Health is suburban Philadelphia's most comprehensive health care resource with over 11,000 employees, offering a full range of medical, surgical, obstetric, pediatric, psychiatric and emergency services. Composed of five hospitals, a medical research institute, physician practices and other specialized facilities and services. Recognized as a Magnet system Main Line Health is committed to the highest standards of patient care, education and research.

Lankenau Medical Center, a 331-bed not-for-profit acute care teaching hospital and medical center, is conveniently located in Wynnewood, PA, just outside the western city limits of Philadelphia, on a magnificent 93-acre campus including its own farm. Lankenau has been recognized by Truven Health Analytics as one of the nation's 100 Top Hospitals for excellence in patient outcomes, patient safety and patient satisfaction. U.S. News & World Report ranked Lankenau as one of the Top 5 hospitals in the Philadelphia region and one of the Top 10 hospitals in Pennsylvania. The Hospital has received Magnet? designation by the American Nurses Credentialing Center (ANCC), the nation's highest award for recognizing excellence in nursing care.

Lankenau is a Level II Trauma Center and in 2013, opened the Heart Pavilion, a world-class facility for cardiac care. We have made it our mission to provide patients with a superior patient experience. This translates to the consistent delivery of safe, high quality clinical care in the absence of preventable harm.

Why Work at Lankenau Medical Center?

We are committed to providing exceptional care with empathy and compassion for people at all stages in life. Our Diversity, Respect and Inclusion Initiative celebrates our differences and our similarities. Ultimately, we want everyone to feel respected for who they are. Our physicians and employees speak highly of the work environment at Main Line Health. The hospital has been recognized by the Philadelphia Business Journal as one of the top ten \"Best Places to Work\" in the Delaware Valley and also ranked among Modern Healthcare's top 100 places in the nation to work in healthcare. With a history spanning more than 150 years, it's one of the region's most honored and respected academic healthcare institutions.

Turn your job into a career by joining Main Line Health! Lankenau Medical Center has an immediate opening for a Full Time Care Coordinator, MSW!

The Care Coordinator MSW (CC-MSW) is responsible for exemplary cross continuum care coordination, inclusive of psychosocial assessments and interventions. This individual works with physicians, peers, community colleagues, and others to orchestrate care across the health care continuum, to identify opportunities to continually improve patient care and services, to improve population health, and to achieve collaborative practices that exemplify Main Line Health System's commitment to patient centered care and community engagement.

Responsibilities Include:

Patient and Family

* Empowers and engages patients and families to represent themselves and advocates the patient's perspective.

* Recognizes the holistic interrelationship that exists within and across the health system and consistently negotiates the best outcomes for the patients and families

* Ensures that the patient and family members experience seamless and safe transitions of care from encounter to encounter

* Ensures face-to-face communication with the patient and/or family within 24 hours of consult request or need identification, or, as soon as medically appropriate in other circumstances and other sites of care; such as the emergency department, physicians office, outpatient bed, urgent care or community care facility, to introduce the role of the CC-MSW and to initiate or update the plan of care and develop the transition of care plan

* Develops patient self management goals, and, with colleagues, monitors the progress of the goals and updates as appropriate

* Ensures that patients and families receive education on health and wellness activities, disease process and interventions, medications, next steps, and other critical factors in overall health maintenance and improvement

* Supports patients in making and getting to healthcare appointments

Cross Continuum Care Facilitation and Coordination

* Consistently employs MLH transition of care standards and is accountable for transitions of care across the continuum

* Conducts proactive case finding in addition to responding quickly to case referrals, and identifies support and intervention activities to support health and prevent disease progression

* Coordinates with law enforcement and Children's Protective Services to complete legally mandated reports in situations of suspected child abuse or neglect, child sexual abuse, adult and elder abuse and neglect, and domestic violence

* Collaborates with outside agencies and patients regarding adoption and newborn surrender

* Works with patients on Advance Directives (ADs), Durable Power of Attorney (DPOA), and identification of a proxy if needed

* Completes preadmission screening and annual resident review (PASARR) for individuals for skilled care and nursing home placements

* Ensures that appropriate resources are identified and scheduled for patients who require continuing psychosocial/mental health interventions or therapy

* Orchestrates and synchronizes care between multiple care delivery sites and multiple caregivers and quickly and efficiently mobilizes resources to support patients and families through a hospital stay and across the continuum of care safely, efficiently and effectively

* Collaborates closely with the Clinical Care Coordinator and physician colleagues on all aspects of care delivery

* Works quickly to address barriers and challenges associated with cross continuum care coordination and engages colleagues and staff in \"hard wiring\" appropriate solutions

* Accountable for accurate and timely documentation and monitors documentation in the medical record daily, to ensure that care is accurately reflected and up to date

* Assists and collaborates in the management of patients with chronic diseases following established protocols and interventions

* Ensures absolute compliance with CMS and other regulatory initiatives

* Assesses total health status, identifies, addresses and includes in the plan of care, contributing factors such as obesity, age, diabetes, medications, etc.

* Ensures that Advanced Care Planning is offered to patients and families consistent with MLH policy

* Coordinates healthcare interventions for populations with significant health conditions in which self-management efforts are critical

* Updates the plan of care and risk score throughout a hospital stay and at every \"site of care\" encounter

* Proactively manages payor communications and issues


* Works with community agencies to arrange services for patients with chronic or complex care needs, or to encourage general wellness and health

* Develops significant population savvy, ensuring that services and interventions address the needs of the market demographic, and are sensitive to cultural and ethnic practices and beliefs

* Understands community health challenges and works with leaders and division staff and colleagues to develop and implement practices, education programs, and other strategies to improve the health of the community and to promote continuous improvement in health status across the continuum

* Establishes significant functional relationships with community providers and community service agencies, monitoring the integrity of care and services

* Visits community care providers to develop rapport, understand service offerings, and insure quality and consistency of services

Physician Engagement/Alignment

* Engages physician partners in care improvement and resource management activities

* Practices proactive case finding and quick response to referrals and consults

* Provides consultation to physicians and staff regarding the patient's psychological, financial, developmental, family, and other pertinent challenges

* Partners with and supports physicians in patient care activities and post acute care planning

* Collaborates with physician(s) to set daily rounding times or meetings based on the physician schedule and what is best for the patient, and provides substantive contributions to rounding

* Proactively communicates with physicians

* Serves as a resource to physicians on health industry trends, rules, regulations, reimbursement, denial management and avoidable days, clinical cost reduction, etc.


* Ensures that the division's mission, vision, and values are actualized

* Provides exemplary customer service to the patient, family, physician, and care team members

* Models and orchestrates consistent, professional communications and maintains consistent and proactive communication patterns with colleagues and staff

* Establishes rapport and relationships with hospital staff and leaders, community physicians, physician practices, and post acute providers

* Highly visible within MLH facilities and the \"market\"

* Responds positively to change

* Delegates responsibilities appropriately, but remains accountable for outcomes

* Excels in, and utilizes, both tactical and strategic communication to prevent duplication and omission of critical information, to expose concerns and issues, and develop trusting relationships.

* Immediately addresses and reports all barriers and challenges impacting safety, quality, cost or efficiency of providing services.

Assessment & Analysis

* Develops a deep understanding of population health data, proactively reviews data, and engages colleagues across the continuum to improve care

* Maintains constant awareness of performance and service outcomes data, inclusive of financial, operational, process, value, and relational coordination measures

* Immediately addresses deficits as they are identified

* Works with colleagues to eliminate avoidable days and denials

* Collaborates with colleagues to quickly address all potential financial losses identified through denial management processes

* Leads and executes clinical cost reduction/containment opportunities

* Identifies, studies and acts upon at least two significant clinical cost reduction activities per year in collaboration with physicians and possibly other clinical partners and reports work process barriers

* Researches and implements opportunities to mitigate performance and utilization risk

* Anticipates and troubleshoots claim and reimbursement issues

* Provides feedback that will enhance payor negotiations


* Participates in pertinent, ongoing, relevant education that contributes to professional knowledge and enhances practical abilities. Attends 70% of division educational programs.

* Attains significant knowledge of Population Based Care, Clinical Integration and Accountable Care

* Teaches at least two educational programs per year to hospital staff and/or physicians

* Participates in and supports research activities

* Develops expertise on payment changes, trends, requirements for patient notifications, forms and other regulations as defined by Centers for Medicare and Medicaid (CMS), and other relevant regulatory bodies.

* Stays abreast of CMS core measures, National Patient Safety Goals (NPSGs) and publicly reported outcomes.

* Maintains proficiency in reimbursement and denials management including physician and hospital, inpatient and outpatient payment structures, payor contracts, and health industry changes

* Develops and maintains significant knowledge of relevant medical/legal issues impacting patient care, including advanced directives, child abuse, and elder abuse


Education: Master's Degree in Social Work from CSWE (Council on Social Work Education) accredited program.

Licensures & Certifications:

* Licensed Social Worker strongly preferred.

Experience: at least 5 years of recent clinical experience in a physician's office, clinic, hospital, or emergency services (EMS) setting, or other equivalent experience. Leadership experience a plus

* We offer competitive compensation and outstanding comprehensive benefits including tuition reimbursement, 403B matching savings plan, a pension plan, and a generous paid time off program. To be considered, please apply online with your resume at Enter Job ID 48331 in Keyword search box.

Applicants must certify that they have not used tobacco products or nicotine in any form in the 90-days prior to submitting an application to Main Line Health. This will be verified during pre-employment testing. We are an Equal Opportunity Employer. Please, no agency calls.


* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.

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