Care Manager

Description JOB SUMMARY

The Care Manager plays a vital role in delivering comprehensive, patient-centered care within an integrated health team at a Federally Qualified Health Center (FQHC). This position supports patients with complex medical, behavioral, and social needs by coordinating services, promoting health education, and facilitating access to appropriate care. The Care Manager works collaboratively with primary care providers, behavioral health providers, community health workers, and other team members to ensure high-quality, culturally competent, and equitable care.

Duties: And responsibilities:

Care Manager Duties

• Care Coordination Develop, implement, and monitor individualized care plans in collaboration with patients and the care team.
• Coordinate care transitions, including hospital discharges, specialty referrals, and community resource connections.
• Provide care through in-person visits, telephone, and telemedicine to ensure continuity.
• Proactively conduct outreach to patients who may benefit from services, introducing available programs and supports.
• Facilitate communication between patients, families, and interdisciplinary team members.

Patient Education and Advocacy Deliver health education and coaching to support chronic disease management and preventive care. Advocate for patients and collaborate with community health workers to address social determinants of health. Assist in issuing medical equipment and supplies, ensuring proper documentation and follow-up.

Data and Quality Improvement Document care management activities and track patient outcomes in the electronic health record (EHR). Partner with the Population Health Manager to analyze reports related to patient outcomes, care gaps, and required data metrics. Participate in quality improvement initiatives and population health strategies. Contribute to the development and refinement of care coordination workflows and reporting tools.

Other Duties

• Promotes and demonstrates
• Hope values of: Gospel motivation, Prayer, Excellence, Stewardship, Patience, Thankfulness, Humility, Service, Dignity through Relationship and Hospitality and Joy Primarily onsite in a clinical setting with occasional community outreach or home visits. May require flexible hours to meet patient needs. Complies with HIPAA and protects patient information. The Care Manager ensures compliance with all 19 Health Resources and Services Administration (HRSA) Health Center Program Requirements. The Care Manager is also expected to actively participate in and support quality improvement activities and the clinical practice team efforts emphasizing the importance of the individual patient and putting the patient’s needs first. Other duties as assigned.