Job Description

General Description:

The Care Manager is responsible for coordinating and delivering care management and related care coordination services for patients with multiple chronic conditions. This position focuses on building trusting relationships with patients, developing individualized care plans, and collaborating with the patient’s care team to improve health outcomes, reduce avoidable hospitalizations, and enhance patient engagement. The role is primarily remote, using phone, electronic health record (EHR) tools, and telehealth platforms to provide services.

Duties and Responsibilities:

• Provide monthly care management services for assigned patients in accordance with CMS guidelines.
• Perform comprehensive assessments, including medical, social, functional, and behavioral health needs.
• Develop, implement, and update patient-centered care plans with input from patients, families, and providers.
• Conduct monthly billable check-ins, track cumulative time, and ensure accurate documentation in EHR.
• Coordinate care across providers, specialists, hospitals, and community resources.
• Support Remote Patient Monitoring (RPM) initiatives by reviewing data, identifying trends, and intervening as needed.
• Provide health coaching and patient education related to chronic disease management.
• Monitor and address care gaps, preventative screenings, and medication adherence.
• Identify and escalate high-risk patients for provider review.
• Maintain accurate, timely, and compliant documentation of all patient interactions.
• Participate in quality improvement initiatives related to care management and population health.

Reporting Relationships

Responsible to:

• Directly supervised by the Chronic Care Management Coordinator

Workers Supervised:

• None

Interrelationships:

• Interacts directly with patients and family members via telephone or MyChart.
• Represents CHC and the practice site to the public in a professional manner.
• Works closely with CCM team, Quality and Population Health team, and providers and staff at all clinics.

This job description is not designed to cover or contain an exhaustive list of activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time, with or without notice.

Requirements

Requirements:

All employees of Carolina Health Centers, Inc. are expected to perform the duties of their job and behave in a manner consistent with the Corporate Philosophy which supports the values of: honesty, integrity, openness, the pursuit of individual and collective excellence, and unwavering mutual respect and appreciation.

In addition, this position requires:

• Education:

- Graduate of an accredited School of Nursing

• Licensure and Credentials:

- Current, unrestricted Licensed Practical Nurse License in South Carolina or a compact state.

• Work Experience:

- Minimum 2 years of nursing experience, preferably in primary care, care management, case management, or chronic disease management.

• Skills:

- Able to read, write and communicate effectively orally and in writing

- Proficient in use of computer and keyboard

- Proficiency in using electronic health records (EPIC preferred)

- Able to establish and maintain effective working relationships

- Excellent interpersonal and communication abilities

- Strong communication skills and ability to build rapport with patients remotely.

- Ability to work independently, manage time effectively, and prioritize patient needs.

- Knowledge of CMS CCM billing guidelines and documentation standards.

- Experience with telehealth, remote patient monitoring, or population health programs.

• Physical Abilities:

- Have the hand-eye coordination and manual dexterity needed to operate a computer, telephone, copier, standard office equipment, and medical equipment.

- Required to talk and have a normal range of hearing and eyesight to be able to collect data and record where appropriate (i.e. computer and/or paper).

- Vision abilities required for this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus

• Work Environment:

- Reliable internet access and private, HIPPA-compliant remote work environment.

- Remote, work-from-home position with structured daily schedule.

- Occasional travel to clinics, training, or community events may be required.

- Computer, phone, and secure access to EHR will be provided.

- Requirements for out-of-town and/or overnight travel are minimal.