Highmark Health·Monroeville, Pennsylvania
This role involves collaborating with the interdisciplinary team to coordinate care across the continuum by focusing on social determinants of health impacting patient wellness and experience. Essential duties include completing comprehensive assessments, implementing interventions, and collaborating on safe transition plans for timely discharge and post-discharge connections.
Job Description: :
$10,000 sign on bonus available
This job collaborates with the interdisciplinary team of providers, clinicians, health plans, and external partners while advocating for patients and families/caregivers to coordinate care across the continuum. The incumbent is an integral member of the Care Management team that works to improve the quality of care, patient experience, and the health of populations and individuals by focusing on the social determinants of health impacting wellness.
Essential responsibilities
Contributes to and/or completes initial and ongoing comprehensive assessment. Provides interventions and implements recommendations after engaging patients and their caregivers/families. Focuses on the individual's risk related to social determinants of health to assure successful coordination of care across the continuum. (30%)
Collaborates to provide the safest transition plan for assigned patients (Inpatient/Observation/ED) to ensure a timely discharge and provide appropriate connection with post-discharge care providers and community-based resources. (25%)
Educates patient, family/caregiver and physician regarding most appropriate level of care post discharge and how to access community support. Advocates for the patient, family/caregiver through effectively communicating with interdisciplinary team members, payers and post-acute partners to assure the safest transition. (20%)
Serves as a resource to provide counseling and intervention related to treatment decisions and end-of-life issues. Drives collaborative conversations to establish goals of care. Provides crisis interventions in cases involving Child Abuse and Neglect, Domestic Violence, Adult and Older Adult Abuse, Institutional Abuse Sexual Assault, Mental Health Disorders, Substance Use Disorders, and Identification of a Surrogate Decision Maker/Guardianship. (15%)
Promotes individual professional growth and development through certification, mentoring/precepting, and/or participation on department/hospital/system committees. (5%)
Supports Department based goals that contribute to the success of the organization. (5%)
Other duties as assigned.
The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
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For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org [HRServices@highmarkhealth.org]
California Consumer Privacy Act Employees, Contractors, and Applicants Notice [https://dokumfe7mps0i.cloudfront.net/oms/4391/document/2026/1/doclib_458575_QLVK9_1769448333304228022_1769448333396/1769448333396.pdf]
Market context
Physician openings in Pennsylvania are often driven by ongoing clinical coverage needs and specialty demand, so competition can be strongest for roles that require board eligibility, Pennsylvania licensure or IMLC eligibility, and preferred fellowship or EPIC experience. Benefits and requirements on this platform are AI-summarized from the original job description, helping you review the key details faster. If you are considering applying, confirm your licensure path and highlight any EPIC or fellowship experience in your materials.