We are looking to build our team with a Case Manager reporting into our VP Clinical Integration and Safety. You will be responsible for supporting care continuity and patient safety by systematically identifying and closing care gaps that fall outside the direct clinician encounter. Working in close collaboration with the clinical team, this role focuses on information integrity within the EHR, transitions of care, medication safety, timely access to specialty services, behavioral health follow-through for patients with unaddressed positive mental health screens, and coordination of durable medical equipment and community-based care support services.
🎯 You Will:
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.
🌟 You Have:
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.
Pay & Perks:
💻 Fully remote opportunity
🩺 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
knownwell, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training. Based on current size of the clinic and HIPAA regulation, providers cannot receive care in clinic and provider’s household members cannot receive primary care in the clinic.
