Case Coordinator Comprehensive Care Clinic (Full Time/...

**Description** Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines. Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work? **LOCATION:** Lancaster, PA - N. Duke St **HOURS:** Full Time (40 hours per week). Days Monday-Friday (8am-4:30pm or 8:30-5pm). The Case Coordinator at our Comprehensive Care Clinic plays a vital role in supporting a dedicated caseload of patients living with HIV, focusing on their psychosocial and medical needs. Working as part of a multidisciplinary team including providers, nurses and members of our Support Services Team, the Case Coordinator conducts comprehensive assessments, identifies patients who may benefit from additional support to address complex needs, and develops individualized care plants to improve health outcomes This role provides proactive outreach, coordinate services across the healthcare system, and acts as a key liaison amongst patients, families, clinic staff, community agencies and support services. The Case Coordinator also assists patients in navigating barriers related to healthcare access, benefits, housing, transportation, and other community resources. Our ideal candidate has 2+ years of prior social service work experience in community health. **Summary:** Evaluates the psychosocial and medical needs of patients considered to be at high risk by identifying emotional, social and environmental strengths and problems related to their diagnosis, illness, treatment and/or life situation. This position will work as part of a defined multidisciplinary team including Case Managers, providers and pharmacist, and community health worker/care navigators to formulate, develop and implement case management goals for the identified patients. This position will also collaborate with physicians and clinical staff toward creating better healthcare outcomes for the identified patients. **Responsibilities:** + In conjunction with the practice team and using an explicit process, identify patients at risk for poor outcomes or experiencing poor coordination of services who would benefit from more intensive follow-up. + Performs initial Triage/ assessment of incoming (New) referrals to department. + Provide proactive outreach to patients to include telephonic, internet or face-to-face encounters. + Manages rising and high-risk patients, including management of patients with multiple co-morbidities or high risk for readmissions to hospital setting, using evidenced-based care management best practices. + Complete a comprehensive assessment of bio psychosocial, cultural and language support and self-management support needs. + Documents assessments, care plans, interactions, and interventions according to the department and health care system guidelines and standards. + Provide coordination with and act as liaison to hospital, long-term care, specialty, home health services, referrals, Emergency department (ED) visits, and post discharge, screenings and tests for care-managed patients. + Collaborates with team members and the health system clinical staff in the development and execution of the plan of care and achievement goals including transition planning from the program. + Acts as a patient advocate by facilitating communication among patients and families, care team providers, health system clinical staff, and program team members about client's psychosocial/ medical issues. Facilitates interdisciplinary conferences, as needed, to review treatment goals and optimize resource utilization. + Develops and maintains relationships with a wide variety of community agencies and facilitates communication between these agencies and patients, families and clinical personnel. + Assists patients to obtain appropriate health care benefits including prescription assistance. + Assist patients in problem-solving potential issues related to the medical conditions, health care system, financial and psychological barriers. + Assists patients and families in areas of resource planning (such as community support services, housing, transportation issues, etc.) and system navigators + Establishes and achieves measurable goals and productivity measures. + Arrange referrals, screenings and test procedures, including for depression and other psychological needs as appropriate + Analyzes data to identify under/over utilization + improve resource consumption + promotes potential reduction in cost and enhances quality of care consistent with organization strategic goals and objectives. Data includes but is not limited to predictive analytics, risk stratification, cost-benefit analysis, financial analysis, clinical outcomes + utilization and practice patterns. + Works collaboratively with team members on projects, continuous quality improvement, and team education. + Works as a team member with emphasis on ensuring internal/external customer needs met. + Attend educational conferences and training. Keep current with social work and health care developments and seek to increase job related knowledge. + Attend and participate in staff, committee, department, and other administrative meetings. + Participates in the on-call responsibilities for this position as required. **Minimum Required Qualifications:** + Bachelor of Arts or Science (Required) + Education Specialization:Bachelor's degree in Social Services or related field. + 2+ years Two (2) years of social worker experience in the community health field. + Excellent verbal and written communication skills. + Excellent Customer service skills. + Proven informal leadership skills. + Ability to work independently, setting priorities to coordinate care plans efficiently. + Ability to work effectively in a fast-paced team environment. + Highly organized and detail-oriented with the ability to perform multiple tasks simultaneously. + Effective behavioral and education strategies, including but not limited to interviewing, teach-back method and self -management support. + Related Clinical Training **Preferred Qualifications:** + Current BLS Certification + One (1) to Two (2) years of social work experience in a medical facility/organization, home care, mental health organization or skilled nursing facility. + Prior case management, project leader and team-based experience. + Experience performing in-home patient visits for assessment, education, training, coaching, etc. /#LI-LJ1 We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives. Live Your Life's Work We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law. REQNUMBER: 309836

Created: 2026-04-02