Care Manager; Hybrid-Remote Job Sylacauga Alabama USA,Healthcare

Conduct structured reviews of clinical records to assess service utilization, client engagement, and treatment plan compliance.
Document all findings and coordination efforts in the electronic health record using the Care Manager System.
Identify gaps in care, missed services, or follow-up needs and take appropriate action.
Care Coordination

Coordinate physical, behavioral, and social health services across internal programs and external providers.
Facilitate client access to community-based services such as housing, benefits, employment supports, and substance use care.
Ensure referrals are generated, tracked, and closed with appropriate documentation.

Care Managers are expected to dedicate the majority of their workday to direct patient care coordination activities. Productivity expectations are as follows

Care Managers will spend 80-90% of their time on patient care coordination, which includes chart reviews, outreach attempts, care coordination tasks, referral management, documentation, and follow-up.
During the initial training period, Care Managers will focus on building proficiency with workflows, documentation standards, and chart review processes. During this time, the number of charts reviewed per day may vary based on learning needs and case complexity.
Once fully trained and able to conduct efficient and thorough chart reviews, Care Managers will be expected to maintain a consistent workflow that aligns with spending 80-90% of time on patient care coordination tasks.
Daily Responsibilities Each day, Care Managers are expected to

Fully work all Hospital/ED/BHCC follow-ups assigned to them.
Complete all missed appointment follow ups.
Work referrals in order of patient risk, ensuring high risk patients are prioritized, followed by moderate-high risk, and then moderate- and low-risk referrals.

Documentation must be completed daily to support timely follow-up, continuity, and closed-loop care coordination.

Primary Job Functions Clinical

Conduct structured reviews of clinical records to assess service utilization, client engagement, and treatment plan compliance.
Document all findings and coordination efforts in the electronic health record using the Care Manager System.
Identify gaps in care, missed services, or follow-up needs and take appropriate action.

Coordinate physical, behavioral, and social health services across internal programs and external providers.
Facilitate client access to community-based services such as housing, benefits, employment supports, and substance use care.
Ensure referrals are generated, tracked, and closed with appropriate documentation.

Conduct follow-up calls within 24 hours of psychiatric or medical hospital discharges.
Confirm follow-up appointments are scheduled, and discharge instructions are supported and understood.
Notify care team members of transitions and facilitate continuity of care.

Monitor client attendance at therapy, psychiatry, and medical appointments.
Address patterns of disengagement, such as missed appointments, and initiate outreach or peer support referrals.
Review PHQ-9 and other screening tools to track clinical progress and inform care needs.

Create, follow up, and close referrals in the Care Manager System.
Communicate with service providers to confirm that referrals were completed and appointments attended.
Resolve barriers such as transportation, insurance, or…