Connected Care Specialist

Job Details

Job Description

Essential Functions

• Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.

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Patient Experience and Service Excellence

• Deliver exceptional service and resolve every transaction with the highest level of professionalism, ensuring a patient experience that reflects our unwavering commitment to efficient and effective care connections. Demonstrate dedication to service excellence and consistent follow-through.

Case Review and Resource Allocation:

• Receive individual cases referred to the Referral Specialist team to determine the types of assistance and resources needed based on Health Related Social Needs (HRSN) and other screening results. This will often involve engaging directly with patients for clarification on needs and other relevant life circumstances and may involve collaboration with care team members when resource coordination is directly relevant to patient care (e.g., medication costs / potential to change medications)
• Triage cases referred to the Referral Specialist team to determine assignment to other team members, when applicable, to ensure efficient management of workload across the team
• Identify and implement the best fit resources for each individual based on eligibility criteria such as medical history, insurance coverage, and screening results.
• Track outcomes including success of individual patient referrals as well as details of what patient needs are unable to be met with current workflows to inform continuous process improvement across the team.

Screening and Referral Activities:

• Conduct HRSN assessments and other critical screenings (e.g., missed/delayed cancer screenings) onsite in various clinical and community settings for patients and community members.
• Document screening results accurately and follow workflows to communicate positive screenings to relevant staff.
• Implement optimal referrals for individuals based on screening results, including but not limited to cancer services, transportation, insurance and benefit support, food and nutrition, primary care and specialists, housing, and safety.
• Educate patients on available resources, guide them on independent access (e.g., setting up rides), and assist in completing necessary paperwork for program approval.
• Conduct follow-up assessments and provide ongoing support to ensure individuals receive services related to referrals (loop closure).
• Schedule appointments for patients as needed with a variety of services.

Collaboration and Communication:

• Collaborate with the care team regarding HRSN results, interventions, and update the team on referral outcomes and patient satisfaction with resources.
• Engage directly with patients and community members to further clarify HRSN-related needs and troubleshoot referrals as needed.
• Interface closely with the other Connected Care Services staff and leadership team to troubleshoot challenges that arise.
• Serve as a direct supervisor to other Connected Care Services staff who are supporting screening and follow up activities, as needed
• Engage regularly with community-based organizations (CBOs) to ensure up-to-date information regarding capacity, client eligibility, referral processes, etc as well as to troubleshoot specific patient referrals and general workflows.
• Support continuous refinement of resource lists across the covered geography.
• Liaison with CBOs as needed to

Documentation and Time Management:

• Complete accurate, timely documentation of all client and care coordination contacts in the electronic health record system (training provided) and other software per program policy.
• Keep clear records of challenges faced in meeting patient needs and other workflow items needed to inform process improvement
• Demonstrate strong time management skills to handle incoming referrals efficiently.

Cultural Competence:

• Apply cultural humility when interacting with clients and staff to ensure respectful and effective communication.

Work Shift

Worker Sub Type

Primary Location Address

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.

Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.