Piedmont Health Services, Inc.
  • Moncure - Moncure Care Management
  • Full Time

Care Manager 
Moncure Community Health Center 
(Bilingual in Spanish and English - Preferred
Full Time Benefit Eligible
 
Job Summary: 
The Care Manager provides ongoing support and expertise through comprehensive assessment, planning, and implementation of the provider-patient care plan and overall evaluation of individual patient needs and barriers to care. The Care Manager promotes patient-centered and team-based care through effective communication with patients, the care management team, medical team and center staff. The Care Manager promotes continuity of care through support in navigating the health system, initiating and following up on referrals, providing outreach to patients who are due or overdue for services, coordinating patient education and case managing high-risk patients.  The Care Manager is also responsible for keeping resources up-to-date and providing monthly reports on center-specific care management data.  Needs to be able to attend monthly meetings on and off site and provides Care Management coverage when needed. 
 
Minimum Qualifications: 
  • Bachelor's degree required, in a healthcare related field is preferred. (nursing, public health or social work)
  • One to two years nursing, case management, or social work experience preferred.  
  • Bilingual Preferred 
Patient Population Served: 
Pediatric, Adolescent, Adult, Geriatric, Prenatal.  Diverse population including but not limited to chronically ill and limited English speaking
patients. 
 
Physical Demands/ Working Conditions: 
Extended periods of walking, standing, and extended periods of sitting. Performance of essential duties requires close and distance vision, hearing acuity, dexterity and stamina. Clinical environment with exposure to chemicals, pathogens and patient body fluids. Ability to work under stressful conditions.
Ability to multitask.  Adaptability to change assignments unexpectedly. Must have a personal vehicle for transportation between sites and to other
community networks within our service area.  Participation in training sessions outside of PHS.  Requires moderate computer skills and use of other
office equipment.  
 
Responsibilities and Duties: 
  • Provides Care Management to PHS patients by helping to reduce barriers to optimal health outcomes.
  • Works with Nursing, Providers, Pharmacy, WIC/Nutrition, Dental, and administration as appropriate to coordinate care for patients
  • Assists in the development of care plans and assess for need to be added to care management case load for high risk patients based on the clinical assessment. Helps to carry out said care plans developed by the clinical team 
  • Follows patients until satisfactory completion of care plan or decrease in risk
  • Prioritizes Care Management referrals from healthcare team at the point of care and ensures those referrals are completed.
  • Coordinates care for Medicaid patients enrolled with CCNC network. May receive referrals from external CCNC care managers or PHS RN care managers.
  • Identifies resource needs for PHS patients and helps link patients with external and internal resources.
  • Coordinates care for CHN patients by ensuring connection to primary care, synchronization of applicable information if needed as well as access to timely follow up appointments from ER, hospitalization, specialty care.
 
 
 
 
 
 
 
Piedmont Health Services, Inc.
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