Care Manager - HH

Full-Time Care Manager

Community Healthcare Network is seeking a Full‑Time Care Manager who will be responsible for guiding chronically ill patients through the health care system by assisting with access issues, developing relationships with service providers, and tracking interventions and outcomes.

Responsibilities include, but are not limited to:

• Provides direct service to a caseload of 50–55 patients with the assistance of a patient navigator.
• Screens for functional scale eligibility, conducts initial assessments, and periodic reassessments of patients’ needs including medical, mental health, substance use, financial, housing and support needs.
• Provides crisis intervention and health education services as needed.
• Develops patient‑focused care plans with documented input and approval from other providers and the patient in compliance with Health Home standards.
• Works with the medical staff to develop, implement, and coordinate the care plan for patients with chronic diseases such as diabetes, asthma, congestive heart failure, hypertension, mental health conditions, and substance abuse, based on the Health Home chronic disease care coordination model standards.
• Conducts home/field visits and maintains patient contact in accordance with program standards.
• Coordinates patient services with internal and external service providers through regular case conferencing.
• Ensures appropriate record documentation from all members of the case management team.
• Documents the outcomes of care plans in the case record.
• Assists in coordinating care with pharmacies, insurance companies, hospital discharge planning and other providers in the Network.
• Facilitates related services for health center patients as appropriate with respect to their confidentiality and privacy.
• Handles protected health information (PHI) in a manner consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
• Performs other duties as assigned.

• BA/BS Degree is required (or AA/AS Degree or equivalent of college credits from an accredited college/university with four (4) years experience in care coordination required).
• MSW/MPH preferred.
• Two (2) years experience in care coordination is preferred.

Entry level

Full‑time

Health Care Provider

Hospitals and Health Care