Care Management Leader for High-Risk Patients

Tapestry; Atlanta (GA); On-site; USD 75,000 - 105,000; Full time

Job summary

Tapestry is seeking a Manager, Licensed Care (LCM) to coordinate screening and provide intervention for patients with complex chronic care needs within our care management program. The role focuses on guiding care teams, leading care plan development, and ensuring high-quality patient outcomes.

Responsibilities include assessing risk, coordinating care across providers, and ensuring timely use of resources to support patients with chronic conditions.

Qualifications

• Current Illinois licensure as a professional nurse (RN) or Clinical Social Worker (LCSW) required.
• Minimum of three years clinical experience with at least one year in disease or care management, required.
• Experience with EMR systems required; Centricity experience desired.
• Proficiency in Electronic Health Record, Microsoft Word and Excel.

Responsibilities

• Identifies, tracks and manages care for the highest risk patients.
• Conducts initial care coordination screening eligibility and performs comprehensive risk assessment.
• Oversees the development and implementation of an integrated patient care plan for each of the highest risk patients.
• Provides ongoing clinical assessment, monitoring and follow up for the high-risk patients.
• Utilizes standing orders and clinical orders for chronic disease management within scope of clinical practice.
• Assesses psychological needs and ability to benefit from community resources and referrals to outside agencies/programs when appropriate.
• Promotes clear communication among a care team and treating clinicians by ensuring awareness regarding patient care plans.
• Performs medication review, reconciliation and coordination with a licensed professional for medication adjustment.

Skills

Communication skills

Time management

Organizational skills

Problem solving

Customer service

Tools

Centricity EMR

Microsoft Word

Microsoft Excel

Job description

Tapestry is seeking a Manager, Licensed Care (LCM) to coordinate screening and provide intervention for patients with complex chronic care needs within our care management program. The role focuses on guiding care teams, leading care plan development, and ensuring high-quality patient outcomes.

Responsibilities include assessing risk, coordinating care across providers, and ensuring timely use of resources to support patients with chronic conditions.