Temporary Chronic Care Manager (Primary Care - Rural Health)

Bright Harbor Healthcare•Bayville, NJ

4d•Hybrid

About The Position

This is a temporary, full-time grant-funded position for a Chronic Care Manager within the Primary Care - Rural Health department. The role is available through October 31, 2026, with potential for continuation. The position is benefits-eligible and located in Toms River, NJ. The Chronic Care Manager will be responsible for developing and implementing individualized care plans for patients with chronic conditions, conducting patient assessments, providing care coordination, monitoring patient progress, and educating patients and caregivers. The role also involves serving as a liaison between various healthcare entities and community organizations, addressing barriers to care for rural populations, supporting transitions of care, and maintaining accurate documentation in the EHR. The work environment is a combination of clinic-based work, remote care coordination, and occasional field visits, with required travel within rural regions of Ocean County, New Jersey.

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.

Nice To Haves

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.