Community Team Care Manager

Community Team Care Manager

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Job Summary
This advanced role serves as both the clinical lead and an individual contributor within an integrated community care team (ICCT). As the team captain of a dedicated community pod, you will oversee care for an assigned panel of members, ensuring continuity and comprehensive support for their total care needs.

Responsibilities include leading a pod of community health workers (CHWs), managing longitudinal and episodic care, providing direct case management to complex members, and serving as the clinical escalation path for CHWs. Success will be measured against value‑based care metrics such as member engagement, utilization management, and quality outcomes.

• Lead a community pod, overseeing health workers in delivering longitudinal and episodic care.
• Participate in the Transitions of Care team to ensure safe discharge planning and reduced readmissions.
• Oversee care for an assigned panel of members within a specific region.
• Provide direct case management for a small panel of the most complex members, conducting comprehensive assessments and person‑centered care plans.
• Develop and delegate tasks for person‑centered care plans, supervising CHWs.
• Lead daily morning huddles to drive accountability toward key performance indicators.
• Conduct quarterly care plan oversight visits.
• Serve as the clinical escalation path for CHWs.
• Participate in population health and panel review meetings.
• Collaborate with primary care providers, specialists, and community resources.
• Ensure documentation meets agency and regulatory standards.
• Support member engagement and transitions of care, addressing barriers to treatment.
• Utilize evidence‑based interventions such as motivational interviewing and trauma‑informed care.
• Facilitate internal referrals to Absolute Care programs.
• Monitor and report on pod and individual KPIs for quality improvement.
• Maintain accurate electronic health record documentation.
• Promote a collaborative, accountable, member‑focused team culture.
• Attend required meetings, trainings, and initiatives as a team captain.

• Willingness and ability to travel up to 80% of the time to member homes, healthcare facilities, and community locations.
• Licensed RN in the state of practice, complying with all regulations.
• Experience in medical and behavioral case management in community settings (CCM preferred).
• At least 3 years of experience serving medically complex populations with behavioral health and socioeconomic barriers.
• Strong leadership experience supervising allied health or CHWs.
• Proficiency in delegating, supervising, and ensuring accountability within matrixed teams.
• Knowledge of value‑based outcomes, NCQA, PCMH, and HEDIS standards.
• Excellent computer skills (Microsoft Office Suite, EMR systems) and communication abilities.
• Valid driver’s license, automobile insurance, and reliable transportation.
• Ability to obtain CCM credential within 24 months of hire (if not already held).

This position is primarily community‑based with occasional office duties. Reliable transportation is required for travel between member locations and the office.

• Communicate clearly and exchange accurate information consistently.
• Remain stationary for long periods while operating computer, phone, and other office equipment.
• Occasionally move objects up to 20 lbs.

None.

Seniority level: Mid‑Senior level
Employment type: Full‑time
Job function: Health Care Provider
Industries: Hospitals and Health Care