Community Based Health Manager, MSW, LSW

Company Overview

At Virtua Health, we exist for one reason - to better serve you. That means being here for you in all the moments that matter, striving each day to connect you to the care you need. Whether that's wellness and prevention, experienced specialists, life‑changing care, or something in‑between - we are your partner in health devoted to building a healthier community.

If you live or work in South Jersey, exceptional care is all around. Our medical and surgical experts are among the best in the country. We assembled more than 14,000 colleagues, including over 2,850 skilled and compassionate doctors, physician assistants, and nurse practitioners equipped with the latest technologies, treatments, and techniques to provide exceptional care close to home. A Magnet‑recognised health system ranked by U.S. News and World Report, we've received multiple awards for quality, safety, and outstanding work environment.

In addition to five hospitals, seven emergency departments, seven urgent care centres, and more than 280 other locations, we're committed to the well‑being of the community. That means bringing life‑changing resources and health services directly into our communities through our Eat Well food access programme, telehealth, home health, rehabilitation, mobile screenings, paramedic programmes, and convenient online scheduling. We're also affiliated with Penn Medicine for cancer and neurosciences, and the Children's Hospital of Philadelphia for paediatrics.

• Location: Lippincott - 301 Lippincott Drive
• Remote Type: On‑Site
• Employment Type: Employee
• Employment Classification: Regular
• Time Type: Full time
• Work Shift: 1st Shift (United States of America)
• Total Weekly
  
  Hours:
  
  40
• Additional Locations: Linwood - 1201 New Road, Suite 150
• Job Information: Preferred - Behavioral Health and Geriatric experience. EPIC and Excel experience.

Onsite, Monday through Friday, no holiday or weekends.

Summary: The Community Based Health Manager is a member of the care team, along the patient's medical provider and psychiatric consultant. Responsible for the clinical assessment, planning, implementation, monitoring and evaluation of case management services through the appropriate utilisation of resources. Providing as needed short‑term psychotherapy including motivational interviewing and behavioural activation. Provides support to primary care clinician and behavioural health team including psychiatrist.

Application of appropriate medical necessity tools to maintain compliance, achieve cost‑effective care and positive patient outcomes. Utilises clinical assessment, critical thinking and decision making to formulate coordination of care with a multi‑disciplinary team, address patient plans of care and transition needs.

Facilitates ongoing patient communication and engagement, care planning, review patient goals, supports discharge needs including social resources, food insecurity, financial insecurity and transportation. Networks with local/community services to identify appropriate resources for patient and family support. Facilitates patient hand‑off from post‑acute service to the community for self‑management.

Clinical Assessment - Conducts comprehensive assessments for chronic disease high‑risk patients and behavioural health using a standardised tool; will review GAD‑7 and PHQ‑9 with individuals, develop a patient‑centred individualised plan of care including patient goals and addresses patient's psychosocial and educational needs. Identifies psychological, social, financial, spiritual and behavioural barriers that may interfere with the patient's treatment plans and outcomes.

Care Coordination - Coordinates appropriate care through assessment and patient advocacy. Communicates and educates patients, family and healthcare team on the plan of care and transition options ensuring patient freedom of choice. Provides brief behavioural interventions using evidence‑based techniques such as behavioural activation, problem‑solving treatment, motivational interviewing, or other treatments as appropriate. Makes appropriate referrals within the scope of…