Care Manager - Remote

Description

Title:

Care Manager
- Onsite
- Houston, TX and surrounding areas

Reports to:

CEO/President

Status:
Full-time (Salary/Exempt)

Date created:
July 16, 2026

The Care Manager is responsible for overseeing and coordinating comprehensive care management services for assigned patients to support improved health outcomes. The Care Manager provides clinical oversight, completes comprehensive patient-centric care plans, care plan revisions, supports care coordinators as needed, ensures appropriate escalation of patient needs, and documents all activities in accordance with organizational and regulatory standards.

• Create, review, and update patient-centered care plans based on physical, mental, cognitive, psychosocial, functional, and environmental assessments, along with an inventory of available resources.
• Provide patients with a written or electronic copy of the care plan and document delivery in the medical record.
• Provide Chronic Care Management (CCM) patients with appropriate education materials and resources to support health education, self-management, and lifestyle improvement.
• Identify patients with gaps in preventive health services and assist with scheduling required screenings or diagnostic tests with their providers.
• Review and update patients’ current allergy and medication profiles, assess adherence and potential interactions, and communicate concerns to the patient and providers as appropriate. Support patient self-management of medications within the Care Coordinator scope.
• Engage patients through monthly care plan reviews that promote healthy lifestyles, close gaps in care, and reduce unnecessary emergency department utilization and hospital readmissions. Coordinate care with patients, caregivers, primary care providers, specialists, community resources, behavioral health partners, and other health plan or system departments as appropriate.
• Document all care management activities in the electronic health record (EHR) or Care Vitality Care Management platform, as applicable, including required time reporting, in accordance with Care Vitality standards. Identify trends and opportunities for improvement based on patient, provider, and system interactions.
• Health Risk Assessments may be incorporated into the role as program needs evolve.
• Escalate patients requiring reassessment or higher-level intervention in accordance with Care Vitality protocols.
• Transitional Care Management Services may need to be provided in any given month as part of the scope of services
• Provide transportation assistance if needed
• Gathering patients consent for various care management and remote monitoring programs
• Setup and training for patients to use specific medical device(s) per their condition.
• Perform other duties as assigned.

• To successfully perform this role, an individual must be able to perform the essential duties satisfactorily. The qualifications listed below represent the knowledge, skills, and abilities required for the Care Manager role. Reasonable accommodations may be made for individuals with disabilities to perform the essential functions.
• Strong time management, focus, attention to detail, and communication skills, with the ability to demonstrate initiative and work independently.
• Ability to effectively multi-task while navigating multiple systems, including the electronic health record (EHR), Care Management and Remote Monitoring platforms, internet applications, email, and Microsoft Office (Outlook, Excel, Word, and PowerPoint).
• Experience accurately documenting time spent with each patient and monitoring assigned patient caseloads to ensure required time and program elements are met for Care Management programs, including CCM, RPM, BHI, PCM, TCM, APCM, and/or RTM.
• Positive attitude with a willingness to receive instruction, feedback, and guidance.
• Effective written and verbal communication skills
• Proficiency in Microsoft Office applications, including Word, Excel, and Outlook

• An active clinical license or credential (such as RN, BSN, LCSW, or equivalent) is required.
• A bachelor’s degree in nursing, social work,…