Community Based Care Manager True North Medical Group LLC Philadelphia, PA Job Details Full-time From $20 an hour 1 day ago Qualifications Social Work License Abuse and neglect policy adherence HIPAA Data summary reports Overseeing care coordination Records management Data management Mental health assessments Clinical documentation Health information regulatory compliance Mandated reporting laws Clinical confidentiality policies Social work care coordination Managing patients as a clinical case manager

Full Job Description Position Summary:

The Community Based Care Manager is a licensed social worker embedded within True North Pediatrics as part of a Provider-Embedded Care Team delivered under the Community Based Care Management (CBCM) Program with Health Partners Plans, Inc. (HPP), in support of the Pennsylvania Physical-Health HealthChoices program. Working alongside nurse navigators, community health workers, and patient navigators, this role provides face-to-face and telehealth-based care coordination for members with high medical and/or social needs. The Community Based Care Manager takes a holistic approach to patient care and education, addressing social determinants of health, promoting preventive services, supporting chronic disease management, and connecting members to clinical, social, and behavioral health resources to improve sustainable health outcomes.

Key Responsibilities:

Member Assessment & Care Planning:

Conduct comprehensive assessments of members' medical, behavioral, and social needs. Partner with members to identify and set individualized health goals. Complete social needs assessments and track referrals to resources. Obtain informed consent and develop Integrated Care Plans (ICPs) for eligible members, in collaboration with Behavioral Health HealthChoices Managed Care Organization counterparts. Represent member goals and preferences to the interdisciplinary care team.

Education & Care Coordination:

Provide education on chronic health conditions and disease selfmanagement. Schedule and support appointments for primary care, specialty care, and testing; accompany members to appointments (medical, welfare, utility, etc.) as needed. Coordinate transportation to and from appointments. Support medication reconciliation and reduce barriers to closing member care gaps. Provide postdischarge support services to reduce preventable readmissions and ER use.

Resource Linkage & Advocacy:

Complete referrals to appropriate resources, including specialists and behavioral health/substance use services. Use Find Help (or a similar platform) to identify and connect members to social needs resources. Provide information and access to nutritional resources such as community food pantries and other social services. Assist members with completion of social service applications. Refer members to community legal services for representation when appropriate. Identify environments that may require notification to authorities (e.g., domestic violence or abuse) and follow mandated reporting protocols.

Documentation & Reporting:

Document all member contacts, interventions, and outcomes in systems capable of supporting CBCM program reporting. Prepare and submit monthly data reports to HPP in accordance with Pennsylvania Department of Human Services (DHS) requirements, including contact details, intervention types, referral categories, care gaps closed, HRQOL results, and ICP data elements. Maintain accurate, timely records in compliance with HIPAA and applicable state and federal confidentiality laws. Participate in collaborative learning sessions and program evaluation activities.

Program Goals This Role Supports:

Improve members' quality of life, as measured by improvement in selfperceived physical/mental health on followup HRQOL surveys. Help members navigate appropriate care to reduce preventable inpatient admissions and emergency room presentations. Increase primary care and specialist visit rates. Reduce rapid readmissions.

Qualifications:

Required:

Active Pennsylvania social work license (LSW or LCSW) or equivalent licensure appropriate to the role, as required under the CBCM contract. Experience conducting psychosocial assessments and care coordination, ideally with pediatric or family populations. Strong understanding of social determinants of health and communitybased resources. Ability to document in electronic systems and complete required program reporting accurately and on time. Excellent communication, organizational, and interpersonal skills. Ability to travel locally for home and community visits and to accompany members to appointments. Knowledge of, or willingness to be trained on, HIPAA and PHI confidentiality requirements.

Preferred:

Prior experience with managed care organizations, HealthChoices, or Medicaid populations. Experience with Integrated Care Plans and coordination with Behavioral Health MCOs. Familiarity with Find Help or similar community resourcereferral platforms. Bilingual/multilingual proficiency relevant to the patient population served.

Working Conditions:

Primarily onsite at True North Pediatrics, with regular facetoface member engagement. Some telehealth/telemedicine followup and home or community visits as needed. Standard business hours, with occasional flexibility to accommodate member and appointment schedules.

Compliance:

This position operates under the terms of the Professional Services Agreement between True North Pediatrics and Health Partners Plans, Inc., and is subject to applicable Pennsylvania PH-HealthChoices subcontractor requirements, including

HIPAA/PHI

confidentiality, non-discrimination, and DHS reporting obligations. About True North Medical Group LLC True North Pediatrics is a unique collection of local pediatric colleagues that have been serving our community for the past 30 years. We are not owned or managed by any big business or larger institutions. You will see familiar names within the True North Group and be cared for by the same exceptional providers. Working together as one group allows us to coordinate the highest quality pediatric care and expand our collective services to meet the needs of your family. While we remain focused on continuing to provide the highest quality and safest care, True North Pediatrics allows us to modernize our practices; focusing on ease of access, transparency in communication, expanded educational resources, expanded therapeutic options and enhanced family engagement to meet and exceed your expectations, while keeping your child's care in our community. We are honored that you chose True North and promise to keep our long standing traditions of excellence at your service.