Temporary Chronic Care Manager (Primary Care - Rural Health)
Bright Harbor Healthcare · Bayville, NJ · 2 mo ago
On-siteManagement$25–$27/hrTemporary
Responsibilities
- Develop, implement, and regularly update individualized care plans for patients with chronic conditions (e.g., diabetes, hypertension, COPD, heart disease)
- Conduct comprehensive patient assessments, including medical, behavioral, and social determinants of health
- Provide ongoing care coordination, including scheduling follow-ups, managing referrals, and ensuring adherence to treatment plans
- Maintain accurate and timely documentation in the electronic health record (EHR) in compliance with regulatory and organizational standards
- Monitor patient progress through regular outreach (phone, telehealth, or in-person visits) and adjust care plans as needed
- Educate patients and caregivers on disease management, medication adherence, lifestyle changes, and preventive care
- Serve as a liaison between patients, primary care providers, specialists, hospitals, and community-based organizations
- Identify and address barriers to care, particularly those affecting rural populations (e.g., transportation, limited provider access, financial constraints)
- Support transitions of care, including hospital discharge follow-ups and coordination with post-acute services
- Participate in quality improvement initiatives and population health management strategies
Requirements
- Bachelor's degree in Nursing, Social Work, Public Health, or a related field preferred
- Minimum of 2-3 years of experience in care management, chronic disease management, or primary care
- Strong understanding of chronic care models and population health principles
- Experience working with underserved or rural populations is preferred
- Excellent communication, organizational, and problem-solving skills
- Proficiency in EHR systems and care management platforms
- Ability to work independently and as part of a multidisciplinary team
Preferred Skills
- Familiarity with telehealth tools and remote patient monitoring
- Knowledge of Ocean County NJ community resources and social service networks