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Position title
Care Manager (RN)

Care Manager will support, advocate, guide and intervene on behalf of their patients and families to ensure successful implementation of the Care Plan.  This role acts as the primary interface between CHDC and other specialty offices and healthcare centers (hospitals).  Care coordinators will assist in providing a medical home for patients with chronic conditions or special health needs.  Support, guide and develop and implement the Medical Home program by working with patients, their families and community resources.


  • Develop and maintain strong working relationships with primary care providers (PCP) to integrate the Medical Home program into CHDC practices, contributing value to the PCP and our patients. Serves as an extension of the PCP office.
  • Assist with policies, guidelines, standing order development.
  • Implements patient-centered plan of care, identifying variances and applying appropriate intervention as necessary.
  • Provide triage care, determining the priority of patients' treatments based on the severity of their condition
  • Follow-up for post-hospitalization, post ED, and post procedural care
  • Provide on-site consultation to PCP and Care Coordination Team providers related to implementation of the Medical Home model including development and documentation of care plans for individual patients, tracking processes, patient self-management support, implementation of clinical practice guidelines and work process/patient flow improvements.
  • Follow-up with patients and families as appropriate.
  • Work collaboratively with Community Health Workers.
  • Works collaboratively with team members and implements an interdisciplinary treatment plan for outpatient care
  • Identifies and manages a small number of high risk/cost patients
  • Facilitates team conferences to review treatment goals, utilization of resources, and educate patient and family
  • Utilizes established documentation standards to maintain quality of care plan documentation to include patient progress toward and barriers to achievement of care plan objectives/outcomes.
  • Develop communication and referral mechanisms to assure that there is seamless communication between CHDC and other healthcare office, the primary care practice and the Care Coordination Team
  • Develop clinical reports for use in PCP records, facilitating physician support of patients in behavior change. Update registries for tracking patients health outcomes and/or improvements
  • Assist the patient in coordination of any additional tests, images and consults with specialists as deemed appropriate by the PCP in developing the Care Plan
  • For assigned patients with multiple prescriptions, assess for efficacy and drug interaction/side effects
  • Assist the patient in mitigating issues and removing barriers to care
  • Conduct patient education in support of Standards of Care (evidence based) guidelines and related health issues using the most appropriate modality for the patient.
  • Achieve SMART goals as assigned.
  • Other duties as assigned.
  • Full unrestricted RN license in the State of Pennsylvania.



  • Minimum 3-5 years clinical experience in any of these areas: acute care, home health, physician office management, managed care organization, provider relations.
  • Physician office experience preferred especially working with physicians to make referrals, provide education to patients both telephonically and in person.
Compliance Provision
  • This position requires compliance with Health Center’s written standards, including its Standards of Conduct and policies and procedures (“Written Standards”). Such compliance will be an element considered as part of the employee’s regular performance evaluation.
  • Failure to comply with Health Center’s Written Standards, which may include the failure to report any conduct or event that potentially violates legal or compliance requirements or Health Center’s Written Standards, will be met by the enforcement of disciplinary action, up to and including possible termination, in accordance with Health Center’s Compliance Program Policy and Procedure: Addressing Instances of Non-Compliance Through Appropriate Disciplinary Actions.
Americans with Disabilities Act Statement

External and internal applicants, as well as position incumbents who become disabled, must be able to perform the essential job specific functions (listed within each job specific responsibility) either unaided or with the assistance of a reasonable accommodation to be determined by the organization on a case-by-case basis.

Employment Type
Health Care
Job Location
351 Schuylkill Rd, PA, 19465, 155
Date posted
January 7, 2021
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Position: Care Manager (RN)

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