Home / Ambulatory Care Manager- MSW (Full-Time/Day Shift)

Ambulatory Care Manager- MSW (Full-Time/Day Shift)


Grant Funded Position. Will follow Amerihealth patients that are experiencing homelessness in multiple care setting to ensure they are connected with appropriate resources. Collaboration with Amerihealth and The Lancaster County Homelessness Coalition is required. Will be required to travel among care settings and provide own transportation

Job Description

LOCATION: Downtown Lancaster, PA.

HOURS: Full-time 1.0 FTE (40 hrs/week); day shift

ESSENTIAL FUNCTIONS: Qualified individuals must have the ability (with or without reasonable accommodation) to perform the following duties:

  • In conjunction with the practice team, identify patients at risk for poor outcomes or experiencing poor coordination of services who would benefit from more intensive follow-up.
  • Provide proactive outreach to patients to include telephonic, internet or face-to-face encounters.
  • Complete a comprehensive assessment of biopsychosocial, cultural and language support and self-management support needs.
  • Provide coordination with and act as liaison to hospital, long-term care, specialty, home health services, referrals, screenings and tests for care-managed patients.
  • Assist patients in problem-solving potential issues related to the health care system, financial and psychological barriers.
  • Be the system navigator and provide direct point of contact access for patient and family questions and concerns.
  • Ensure open communication regarding patient interactions with physicians and office staff.
  • Arrange referrals, screenings and test procedures.
  • Screen and refer as appropriate for depression and other psychological needs.
  • Maintain ongoing appropriate documentation on care coordination to promote team awareness, ensure patient safety, and follow through.
  • Assume advocate role on patient’s behalf with carriers to ensure approval of necessary supplies/services for patient in a timely fashion.
  • Identify and utilize cultural and community resources; establish and maintain relationship with identified service providers.
  • Provide medication management, including medication reconciliation and making recommendations to primary care provider for medication changes based on evidence-based protocols.
  • Provide chronic disease and self-management education and support.
  • Works closely with their assigned primary care practices to offer an individualized assistance with improving and maintaining quality patient care.
  • Oversees and guides the development of multiple health partnerships to achieve a positive e health effect.
  • Manages rising and high-risk patient, including management of patients with multiple co-morbidities or high risk for readmissions to hospital setting, using a care management platform/analytics.
  • 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.
  • As RN primary role of regional team will lead in facilitating transitions and referrals within the LGH health system as well as working with payors to refer appropriately to programs
  • Computer skills-utilization of EPIC, Excel, outlook, Microsoft word , intranet, etc.
  •   Attends periodic educational functions/conferences to enhance program knowledge.


  • Social Worker:  Master’s degree in Social Work (MSW) from an accredited school or program.
  • Three (3) years of  social work experience.
  • 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 educational strategies, including, but not limited to: Motivational interviewing, teach-back method and self-management support.


  • Knowledge of Utilization review or managed care
  • Licensure with Commission for Case Managers (CCM), or expected to obtain within two (2) years of employment.

Disclaimer: This job description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills, efforts, or working conditions associated with the job.  It is intended to be a reflection of those principal job elements essential for recruitment and selection, for making fair job evaluations, and for establishing performance standards.  The percentages of time spent performing job duties are estimates, and should not be considered absolute.  The incumbent shall perform all other functions and/or be cross-trained as shall be determined at the sole discretion of management, who has the right to amend, modify, or terminate this job in part or in whole.  Incumbent must be able to perform all job functions safely.

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Benefits At A Glance:

PENN MEDICINE LANCASTER GENERAL HEALTH offers the following benefits to employees:

  • 100% Tuition Assistance at The Pennsylvania College of Health Sciences
  • Paid Time Off and Paid Holidays
  • Shift, Weekend and On-Call Differentials
  • Health, Dental and Vision Coverage
  • Short-Term and Long-Term Disability
  • Retirement Savings Account with Company Matching
  • Child Care Subsidies
  • Onsite Gym and Fitness Classes


PENN MEDICINE LANCASTER GENERAL HEALTH is an Equal Opportunity Employer, committed to hiring a diverse workforce. All openings will be filled based on qualifications without regard to race, color, sex, sexual orientation, gender identity, national origin, marital status, veteran status, disability, age, religion or any other classification protected by law.


Search Firm Representatives please read carefully: PENN MEDICINE LANCASTER GENERAL HEALTH is not seeking assistance or accepting unsolicited resumes from search firms for this employment opportunity. Regardless of past practice, all resumes submitted by search firms to any employee at PENN MEDICINE LANCASTER GENERAL HEALTH via-email, the Internet or directly to hiring managers at Penn Medicine Lancaster General Health in any form without a valid written search agreement in place for that position will be deemed the sole property of PENN MEDICINE LANCASTER GENERAL HEALTH, and no fee will be paid in the event the candidate is hired by PENN MEDICINE LANCASTER GENERAL HEALTH as a result of the referral or through other means.

LGH Full Time Posted on 07/25/2022