Chronic Care Manager (Primary Care - Rural Health)

Bright Harbor Healthcare•Bayville, NJ

6d•Hybrid

About The Position

The Chronic Care Manager will be responsible for developing, implementing, and updating individualized care plans for patients with chronic conditions. This role involves conducting comprehensive patient assessments, providing ongoing care coordination, and monitoring patient progress through various outreach methods. The manager will also educate patients and caregivers, serve as a liaison between healthcare providers and community organizations, and address barriers to care, particularly for rural populations. Support for transitions of care and accurate documentation in the EHR are also key responsibilities. The position is grant-funded through October 31, 2026, and involves a combination of clinic-based work, remote care coordination, and occasional field visits within rural Ocean County, New Jersey.

Requirements

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.
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.

Nice To Haves

Bachelor’s degree in Nursing, Social Work, Public Health, or a related field preferred.
Experience working with underserved or rural populations is preferred.
Familiarity with telehealth tools and remote patient monitoring.
Knowledge of Ocean County NJ community resources and social service networks.

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.
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.
Maintain accurate and timely documentation in the electronic health record (EHR) in compliance with regulatory and organizational standards.
Participate in quality improvement initiatives and population health management strategies.