Philadelphia FIGHT

Targeted Care Manager

Hours: Mon Fri 9am-5pm

Department: Client Services

Home base: TBD

Supervisor(s): Targeted Care Manager Supervisor

Full-Time, 40 hours per week; Exempt

Job Description

Philadelphia FIGHT is a leading Federally Qualified Health Center with four clinical sites, providing access to state-of-the art, culturally competent primary care, advocacy, social services, consumer education, and outreach for all patients in need, regardless of HIV status or insurance status. Each clinic has a unique focus, these include: primary care for People Living with HIV, primary care for individuals returning from incarceration, primary care for pediatrics, adolescent, and young adults, primary care for people experiencing homelessness, primary care for injection drug users, gender affirming care, dental and behavioral health.

Providing patients with care management services is a vital component in providing to their medical care. Applicants with experience in data analysis, direct service, public benefits, a commitment to social justice, and value healthcare as a human right are encouraged to apply.

Job Summary

The Targeted Care Manager will work with MCO Keystone First and Philadelphia FIGHT's internal data analysis to identify patients from John Bell Health Center, YHEP Health Center and Broad St. Ministries Clinic with high risk for hospital admissions and readmissions and/or emergency room visits. This includes implementing engagement strategies for connecting patients with their medical providers with the goal of reducing emergency room visits and hospital admissions. This position includes connecting patients to necessary resources such as public benefits, medication assistance programs, shelter/housing, food banks, substance treatment programs, behavioral health programs, and other necessary resources that will enhance clients' lives.

Tasks and Responsibilities

• 
  Conduct and document engagement/outreach activities for members not actively engaged and/or who have not been offered services.
• Complete Social Determinates of Health Assessment (SDOH) for eligible PCMH TOP 5% HIGH COST/HIGH RISK
• Provide and document direct service interventions or community resource referrals to address SDOH domain/s assessed as "vulnerable" or "crisis"
• Coordinate linkage to care for patients in need of new patient appointments, re-engagement appointments, follow-up/regular appointments. and urgent care visits
• Track medical appointments and provide appointment adherence support and interventions
• For individuals screened as homeless/unstably housed, provide a focused intervention to connect the patients to appropriate resources such as substance use, mental health, etc.
• Complete preventative services education intervention for all individuals engaged.
• Provide trauma-informed therapeutic support in collaboration with interdisciplinary team, including crisis situations.
• Identify appropriate resources and external support systems to address client needs including advocating and negotiating linkages to resources.
• Available to provide home visits and accompany clients to medical appointments and outside treatment facilities as appropriate.
• Maintain confidentiality standards in accordance with applicable laws and regulations, specifically including the Health Insurance Portability and Accountability Act (HIPAA) and the Confidentiality of HIV Related Information Act (Act 148).
• Perform other duties as assigned.
• Contribute as a team member and share in the responsibilities required to maintain operations and serve the mission of Philadelphia FIGHT. This includes, but is not limited to, obtaining training, participating in events, flexibility in scheduling, covering the commitments of coworkers when they are unable, and other duties as assigned.

Qualifications

• Minimum of a bachelor's degree in social work (or related field) from an accredited college is required. MSW preferred.
• Knowledge and familiarity with local social services resources.
• Ability and desire to work productively with highly stigmatized and diverse populations using a strength-based framework.
• Excellent interpersonal skills and ability to work collaboratively with clinicians and patients.
• Ability to exercise crisis interventions.
• Bilingual (Spanish/English) is highly desired.
• Ability to work from home with WiFi / Computer Access as needed.

Salary: Competitive

Physical Demands:

• Ability to work under pressure and be creative and analytical.
• Ability to continuously stand, walk or sit.
• Ability to work at a computer screen for long periods of time.
• Ability to bend, climb stairs frequently.
• Ability to lift or push up to 10 pounds infrequently.
• Ability to squat occasionally.
• Availability for occasional work outside of regular office hours.

Work Environment:

• Generally works in a clinical office environment but may occasionally be required to perform job duties outside of the typical clinical setting.
• Hybrid office/work from home setting.

Note: Initial probationary period is three months. Benefits including health benefits as per employee handbook begin on the first day of work.

FIGHT is an EEO, Affirmative Action, LGBTQIA, and people living with HIV/AIDS and protected Veterans institution.

Philadelphia FIGHT requires proof of completed COVID-19 vaccination series for all new employees hired. Medical and religious exemptions will be honored consistent with EEOC regulation.