Case Manager

Job Summary

We are seeking a Case Manager to join our dynamic team at knownwell. Reporting to the VP Clinical Integration and Safety, you will support care continuity and patient safety by systematically identifying and closing care gaps.

Responsibilities

• 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 integrate 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.

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.