Case Management Specialist: Chronic Care & Coordination

Eastern Shore Rural Health System; New Church (VA); On-site; USD 28,000 - 58,000; Full time

Job summary

Eastern Shore Rural Health System in Virginia is seeking a Case Management Specialist to coordinate care for patients with chronic conditions. The role focuses on improving engagement, guiding patients through preventative services, and linking them to community resources while working with providers, patients, and insurers.

The position requires an LPN/RN license or MA certification with 5+ years of clinical experience, strong Excel skills, and excellent communication.

Qualifications

• LPN/RN license with clinical experience required, or MA certification with at least five years in a medical setting.
• Clinical experience with chronic disease management and knowledge of life cycles required.
• Proficient in Microsoft Excel.
• Strong communication, professionalism, and teamwork.

Responsibilities

• Identify patients at risk for attribution loss and coordinate care to improve engagement and self-care management.
• Monitor ER/discharge reports to identify high-risk patients and coordinate services.
• Initiate daily transitions of care visits.
• Close healthcare gaps to improve UDS and HEDIS measures.
• Generate at least 750 telephone encounters annually; Medicare outreach ~150/month.
• Access EMR and coordinate with hospital case management and SNF staff.
• Attend at least two community events per year.
• Other duties as assigned by the Case Management Coordinator.

Skills

Chronic disease management knowledge

Excellent communication skills

Bilingual patient care (preferred)

CPR certification

Education

LPN/RN license with clinical experience OR MA certification (5 years clinical experience)

Tools

Microsoft Excel

Job description

Eastern Shore Rural Health System in Virginia is seeking a Case Management Specialist to coordinate care for patients with chronic conditions. The role focuses on improving engagement, guiding patients through preventative services, and linking them to community resources while working with providers, patients, and insurers.

The position requires an LPN/RN license or MA certification with 5+ years of clinical experience, strong Excel skills, and excellent communication.