Remote Care Manager

About the Role
We are seeking a patient-centered, empathetic, and highly organized Remote Care Manager. In this role, you will engage members telephonically to identify health-related social needs, navigate community resources, and build meaningful care plans that directly address social determinants of health (SDOH).
If you thrive in a collaborative virtual environment and have a passion for supporting Medicaid populations and breaking down barriers to care, this role offers an opportunity to make a direct impact.

Key Responsibilities

Member Screening & Needs Assessment

• Conduct outbound phone outreach to assess social determinants of health (e.g., housing instability, food insecurity, transportation, access to care).
• Complete comprehensive social needs assessments and identify gaps in care or unmet community resource needs.
• Build rapport with members and caregivers to understand their individual circumstances, goals, and barriers.
• Prioritize outreach and support based on member acuity, risk factors, and identified social needs.

Care Coordination & Follow-Up

• Develop and implement individualized, member-centric care plans based on assessment findings.
• Coordinate referrals to community-based organizations, healthcare providers, and social service agencies.
• Conduct proactive follow-up outreach via phone, text, or digital platforms to ensure successful service connection.
• Identify and resolve ongoing barriers to care, including transportation, financial challenges, language barriers, and access issues.

Referral Management

• Manage, track, and document referrals to confirm services are successfully received.
• Monitor referral statuses and verify completion through established care management workflows.
• Follow up with community partners, providers, and service organizations to verify outcomes and member engagement.
• Escalate unresolved referrals or service delays according to protocol.

Member Engagement & Education

• Educate members and caregivers on available healthcare options, local programs, and community resources.
• Support members in navigating healthcare systems and social service networks.
• Utilize motivational interviewing techniques and culturally competent communication to encourage self-advocacy and engagement.
• Promote ongoing adherence to care plans and recommended services.

Documentation & Data Management

• Accurately document all member interactions, assessments, referrals, and outcomes in the Electronic Health Record (EHR) or care management platform in a timely manner.
• Maintain strict compliance with HIPAA, organizational policies, and regulatory requirements.
• Track key performance indicators (KPIs), such as referral completion rates, closed care gaps, and engagement metrics.
• Generate timely reporting on referral outcomes and intervention activities.

Collaboration & Quality Improvement

• Collaborate closely with interdisciplinary teams, including nurses, social workers, healthcare providers, and community partners.
• Participate actively in case reviews, team meetings, and quality improvement initiatives.
• Identify trends and opportunities to streamline referral workflows and improve overall care coordination effectiveness.
• Drive initiatives to improve health outcomes across the member population.

Qualifications

• Experience:
  Experience working with Medicaid populations, managed care organizations, or community health environments strongly preferred.
• Core Competencies:
  Proven experience addressing social determinants of health (SDOH) and navigating local social services.
• Communication Skills:
  Strong telephonic communication skills, including experience with motivational interviewing and culturally competent care.
• Technical Skills:
  Familiarity with Electronic Health Records (EHR) and care management software; comfortable working independently in a remote environment.
• Attributes:
  High degree of empathy, problem-solving ability, self-motivation, and attention to detail.