Case Manager

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Live Oak, TX, US

7 days ago Requisition

Salary: $60,000.00 Annually

Case Manager (Primary Care)

The Case Manager serves as a patient advocate and care coordination resource within the primary care setting. This role supports providers, patients, and clinic staff by facilitating access to healthcare and community resources, coordinating continuity of care, addressing Social Determinants of Health (SDOH), assisting with chronic disease management, and reducing barriers that impact patient outcomes. The Case Manager collaborates with providers, clinical staff, referral coordinators, behavioral health, and community agencies to improve quality outcomes, patient satisfaction, and compliance with regulatory and payer requirements.

• Coordinate patient care across the continuum in collaboration with providers and interdisciplinary teams.
• Assist patients with navigating healthcare services, specialty referrals, diagnostic testing, and follow‑up appointments.
• Identify barriers to care and develop individualized care coordination plans.
• Promote continuity of care following hospitalizations, emergency department visits, and specialty consultations.
• Monitor high‑risk patients and assist with chronic disease management initiatives.

• Screen patients for Social Determinants of Health using approved screening tools.
• Connect patients with community resources including:
  • Food assistance
  • Utility assistance
• Maintain an up‑to‑date resource directory for the communities served.
• Advocate for patients experiencing financial, social, behavioral, or medical barriers.
• Assist patients in understanding available healthcare resources and insurance benefits.
• Provide education regarding available support services. Medication Assistance

• Assist patients with medication affordability programs.
• Coordinate prior authorization support with clinical teams when appropriate.
• Assist patients with manufacturer assistance programs and prescription resources.
• Reinforce medication adherence education as directed by the provider.

• Educate eligible patients regarding Advance Care Planning.
• Assist patients in completing Advance Directive and ACP documentation in accordance with organizational policy and applicable law.
• Coordinate provider review and required documentation.
• Ensure ACP documentation is properly scanned into the medical record.

• Assist providers with completion of medical necessity forms and other clinical documentation as appropriate.
• Coordinate completion of disability, FMLA, DME, prior authorization, and community resource paperwork.
• Track outstanding forms to ensure timely completion.
• Educate patients regarding disease management, preventive care, medication compliance, available resources, and follow‑up recommendations.

• Document patient interactions accurately within the electronic medical record.
• Maintain HIPAA compliance and patient confidentiality.
• Follow CMS, Medicare, Medicaid, commercial payer, and organizational documentation standards.
• Participate in quality improvement initiatives and population health programs.
• Work closely with:
  • Medical Assistants
  • Community organizations
  • Skilled Nursing Facilities
  • Home Health agencies
  • Social service organizations

• Associate's or Bachelor's degree in Social Work, Nursing, Healthcare Administration, Psychology, Human Services, or related healthcare field preferred.
• Minimum of two (2) years of healthcare, care coordination, social services, or case management experience preferred.
• Experience in outpatient primary care strongly preferred.
• Knowledge of Medicare, Medicaid, and commercial insurance preferred.

• Excellent communication and interpersonal skills.
• Strong organizational and time management skills.
• Knowledge of community resources and social service programs.
• Ability to manage multiple priorities simultaneously.
• Strong problem‑solving and critical…