Case Manager - Integrated Patient Care Program

Position Summary

The Case Manager will play a central role in implementing the Integrated Patient Care Program by overseeing frontline care coordination activities. Reporting to the Program Manager, the Case Manager will directly supervise Social Workers and Community Health Workers and work closely with partner agencies to ensure patients receive coordinated medical, dental, vision, and social support services. In addition to supervising Social Workers and Community Health Workers, the Case Manager maintains an active case management portfolio to support direct service delivery and model best practices in integrated care coordination.

This role focuses on execution, care coordination, team supervision, and partner engagement
, ensuring program strategies translate into measurable patient outcomes.

• Supervise Social Workers and Community Health Workers, providing guidance, training, and performance support.
• Coordinate patient referrals, follow-up, and care navigation across partner clinics and service providers.
• Ensure consistent use of common intake, referral, and documentation processes.

• Work with the Program Manager to implement program strategies related to social determinants of health, patient education, and telemedicine.
• Support integration of community health workers and student interns into program operations.
• Monitor patient progress and service utilization to support outcome measurement.

• Serve as a day-to-day operational contact for partner agencies related to case management and referrals.
• Participate in partner meetings and continuous improvement discussions.
• Help identify gaps in services and opportunities to strengthen referral pathways.

• Track case management activities, referrals, and patient outcomes.
• Contribute to quarterly reviews of individual- and system-level outcomes.
• Support documentation of best practices and program learnings for replication.

• Bachelor’s degree required;
  Master’s degree in Social Work, Public Health, or related field preferred.
• Minimum 3–5 years of experience in case management, care coordination, or community-based health services.
• Experience supervising staff or leading frontline teams preferred.
• Familiarity with social determinants of health, community resources, and patient navigation.
• Strong interpersonal, organizational, and documentation skills.
• Ability to work collaboratively across multiple organizations and disciplines.