Case Manager

knownwell

20d•$75,000 - $85,000•Remote

About The Position

knownwell is a weight-inclusive healthcare company dedicated to transforming obesity care delivery. We offer a comprehensive range of services including weight management, primary care, nutrition counseling, and health coaching, utilizing a hybrid model of in-clinic and virtual support. With significant funding and a mission to expand access to evidence-based obesity care nationwide, we are rapidly growing and seeking to add a Case Manager to our team. This role reports to the VP Clinical Integration and Safety and is crucial for ensuring care continuity and patient safety by identifying and addressing care gaps outside of direct clinical encounters. The Case Manager will collaborate closely with the clinical team, focusing on EHR information integrity, transitions of care, medication safety, access to specialty services, behavioral health follow-through, and coordination of durable medical equipment and community-based support services.

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.

Responsibilities

Complete biopsychosocial assessments to identify clinical, behavioral, and social needs.
Proactively identify and resolve gaps in the patient record caused by results generated outside the practice's EHR.
Import or document 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 the clinical team to maintain an accurate, current medication list and identify 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 ensure 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 behavioral 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.