This position is hybrid, with some onsite and remote work.

Compensation (Based on experience and qualifications): $63,000 to $78,000

Esperanza Health Centers offers benefits to all its full-time employees:

BCBS Medical PPO Plans | Ameritas Dental |Eye Med Vision | Tuition Reimbursement up to $5,000 per year|10 Paid Holidays and 21 Days of Paid Time Off

The Care Manager is responsible for coordinating screening and providing the intervention of patients with identified complex chronic care needs. The care manager acts as a connector between patient needs and the resources provided by the care management program. This position provides guidance and leadership through the care management program to Esperanza’s care teams and ensures patients receive the best possible care.

Primary Duties and Responsibilities:

1. Identifies, tracks and manages care for the highest risk patients using the electronic medical record and other health information platforms

2. Conducts initial care coordination screening eligibility and performs comprehensive risk assessment, either in person or over the phone

3. Manages a caseload of 62 patients

4. Oversees in the development and implementation of an integrated patient care plan for each of the highest risk patients, either in person or over the phone

5. Supports other care managers and primary care teams with the highest risk patients

6. Ongoing clinical assessment, monitoring and follow up for high risk patients

7. Utilize standing orders and clinical orders for chronic disease management within scope of clinical practice

8. Assesses psychological needs and ability to benefit from community resources and referrals to outside agencies/programs when appropriate

9. Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.

10. Performs medication review, reconciliation and coordination with a licensed professional for medication adjustment

11. Oversees transitions of care process and connects patients to post discharge follow up

12. Participates in the evaluation of the care management programs, which includes running data reports in the electronic medical record

13. Collaborates and participates in the selection, development and maintenance of patient education materials related to healthy lifestyle changes and specific disease management topics.

14. Makes hospital visits, as needed, on a case by case basis, to perform comprehensive risk assessments and to manage the transition of care between the hospital and the primary care setting.

• Master’s level behavioral health (e.g., MSW).you Must have IL licensure (e.g., LSW, LPC).
• 1-3 years of experience in disease management or care management.
• Experience working with medically and behaviorally complex patients preferred, but not required.
• Experience working with children who receive special education preferred, but not required.
• Ability to speak, read and comprehend English and Spanish.
• Displays strong time management and organizational skills in a high intensity work environment.
• Experience working in healthcare and/or a primary care setting preferred.
• Flexibility to work evenings and/or weekends, if necessary. Must be able to work on-site as needed. Current hybrid schedule.
• Proficient in Electronic Health Record, Microsoft Word and Excel.

Esperanza Health Centers is an Equal Opportunity Employer (EOE) according to Title 44, Ill. Administrative Code, and Subpart C Section 750.150.