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knownwell

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Case Manager

Location

United States

Posted

7 days ago

Salary

$75K - $85K / year

Seniority

Mid Level

Professional Certificate2 yrs expExperience acceptedEnglish

Job Description

Case Manager

knownwell

• Complete biopsychosocial assessments to identify clinical, behavioral, and social needs. • Proactively identifies and resolves gaps in the patient record caused by results generated outside the practice's EHR. • Import or documents retrieved results into the practice EHR in accordance with workflow standards, flagging any clinically significant findings for timely clinician review. • Obtain and integrates clinical documentation following unplanned or acute care episodes to ensure safe, informed follow-up. • Schedule timely post-discharge or post-ED follow-up appointments in accordance with practice protocols (e.g., within 7 days of hospital discharge). • Work with clinical team to maintain an accurate, current medication list and identifies discrepancies requiring clinical resolution following care transitions or identified data gaps. • Facilitate timely access to specialty care for patients with time-sensitive clinical needs and ensures every referral, urgent or routine, is tracked from initiation through documentation of results in the chart. • Track patients with labs (e.g., HbA1c, INR, renal panels), imaging, preventative screenings, etc to identify those overdue or whose results have not been returned to the record. • Assist in coordinating referrals and care ordered by a clinician including but not limited to home health, durable medical equipment, community-based resources and other clinical assessments. • Ensure that patients with positive depression, anxiety, or behavior health screenings receive timely clinical attention and connection to appropriate care. • Serve as a consistent point of contact for patients and families managing complex health situations. • Participate in regular huddles and care team meetings to present open care gaps, transitions of care, DME coordination status, and behavioral health follow-up status. • Maintain accurate, timely documentation in the EHR for all care management activities. • Adhere to HIPAA and all applicable privacy and confidentiality requirements in all communications with external facilities, specialists, DME vendors, community organizations, and BH providers.

Job Requirements

  • Licensed practical nurse (LPN), registered nurse (RN), licensed social worker (LSW/LICSW), or equivalent clinical training preferred; medical assistant with care management experience considered.
  • Experience in primary care, care coordination, or case management strongly preferred.
  • Proficiency with athenahealth, including referral management, tasking, document upload, and registry/reporting tools; familiarity with health information exchanges and transitions of care workflows.
  • Familiarity with community resources, insurance authorization workflows, and care transitions.
  • Strong organizational skills and ability to manage a multi-patient registry across concurrent workflows.
  • Knowledge of community behavioral health resources and comfort initiating BH-related conversations with patients.

Benefits

  • Medical, dental, and vision insurance
  • 401K retirement plan with company match
  • Up to 20 days of PTO per year + company holidays
  • Up to 14 weeks of parental leave (12 for non-birthing parents)
  • Annual work from home stipend for remote employees

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