Job Description

Position Title: Chronic Care Manager (Primary Care - Rural Health)
Position Type: Temporary Full Time; 35 Hours Weekly; this is a grant funded position available through October 31, 2026. (Potential for Continuation)
Benefits Eligible: Yes
Location: Toms River, NJ
Department: Primary Care - Rural Health
Salary: $25.00 - $27.00 hourly

Responsibilities:

• Develop, implement, and regularly update individualized care plans for patients with chronic conditions (e.g., diabetes, hypertension, COPD, heart disease).
• Conduct comprehensive patient assessments, including medical, behavioral, and social determinants of health.
• Provide ongoing care coordination, including scheduling follow-ups, managing referrals, and ensuring adherence to treatment plans.
• Monitor patient progress through regular outreach (phone, telehealth, or in-person visits) and adjust care plans as needed.
• Educate patients and caregivers on disease management, medication adherence, lifestyle changes, and preventive care.
• Serve as a liaison between patients, primary care providers, specialists, hospitals, and community-based organizations.
• Identify and address barriers to care, particularly those affecting rural populations (e.g., transportation, limited provider access, financial constraints).
• Support transitions of care, including hospital discharge follow-ups and coordination with post-acute services.
• Maintain accurate and timely documentation in the electronic health record (EHR) in compliance with regulatory and organizational standards.
• Participate in quality improvement initiatives and population health management strategies.

Work Environment & Travel:

• Combination of clinic-based work, remote care coordination, and occasional field visits.
• Travel within rural regions of Ocean County New Jersey may be required.

Requirements

• Bachelor’s degree in Nursing, Social Work, Public Health, or a related field preferred.
• Minimum of 2–3 years of experience in care management, chronic disease management, or primary care.
• Strong understanding of chronic care models and population health principles.
• Experience working with underserved or rural populations is preferred.
• Excellent communication, organizational, and problem-solving skills.
• Proficiency in EHR systems and care management platforms.
• Ability to work independently and as part of a multidisciplinary team.

Preferred Skills:

• Familiarity with telehealth tools and remote patient monitoring.
• Knowledge of Ocean County NJ community resources and social service networks.

Benefits

• Birthdays off
• 12 Paid Holidays
• Sick Days
• Personal Days
• Days Accrued Vacation
• Medical/Dental/Vision
• Company paid Life Insurance and Long-Term Disability
• 403B Plan with Company Match
• Opportunities for training/education/Continuing Education Credits
• Opportunities for Public Loan Forgiveness
• Opportunities for Tuition Discounts from Participating Institutions