Provide integrated whole-person care management for Medicaid-enrolled members across North Carolina, coordinating services and ensuring quality outcomes.
Responsibilities
Conduct member assessments and develop care plans
Coordinate across physical, behavioral, and long-term services
Provide education and self-management support
Monitor and evaluate intervention effectiveness
Facilitate referrals to community resources
Requirements
Bachelor's degree in a health-related field
Nice to have: Bilingual
Nice to have: CCM certification
Nice to have: Experience with child welfare system
The Transitional Care Coordinator (TCC) ensures smooth transitions of care for patients discharged from the hospital, coordinating with multidisciplinary teams and following up to reduce readmissions.
Compensation
The hourly rate for this position is $65.86 - $90.56.
Responsibilities
Meet eligible patients prior to discharge
Introduce program and identify barriers
Call patients 24-48 hours post discharge
Conduct daily virtual calls for Virtual Home Program patients
Serve as resource and educator for 30 days post discharge
The Care Manager - RN is responsible for coordinating and overseeing discharge planning, transitions of care, and case management activities to ensure optimal patient outcomes.
Responsibilities
Conducts daily reviews of medical records to assess the appropriateness of admission, continued hospital stay, and utilization of diagnostic services
Collaborates with interdisciplinary teams (IDT) to ensure effective communication and coordination of patient care, including identifying avoidable days and resolving care transition issues
Develops and implements discharge plans, coordinating post-hospital placement and social services to meet patient needs
Refers cases to physicians or managers when patients do not meet established criteria, ensuring timely and appropriate interventions
Serves as a liaison with community agencies, maintaining relationships and facilitating seamless transitions for discharged patients
Supports the manager in the coordination of daily care management operations while serving as a clinical and operational expert for the team.
Compensation
Pay Range: $44.76 - $67.19/hr. (depends on years of experience)
Responsibilities
Coordinates daily case management operations, including patient assignments, workload balancing, staffing coverage, and workflow prioritization to support efficient patient care delivery.
Serves as the primary resource and escalation point for complex patient cases, care coordination challenges, and day-to-day operational issues.
Provides guidance, coaching, and real-time consultation to case management staff regarding assessment, care planning, transitions of care, resource utilization, and regulatory requirements.
Supports onboarding, orientation, competency development, and ongoing professional growth of case management team members through education, mentorship, and knowledge sharing.
Monitors case management workflows, documentation practices, and required regulatory activities to promote compliance, quality, consistency, and timely completion of work.
Responsible for the full client care cycle including: assessing, planning, implementing, monitoring, and evaluating actions required to meet the clients’ health and human services needs.
Responsibilities
Coordinate and provide care that is safe, timely, effective, efficient, equitable, and client-centered
Maintain case load and utilization by maintaining regular contact with clients to monitor and assess progress
Handle case assignments, draft service plans, review case progress and determine case closure for review and/or consult with supervisor
Deliver on-going services to clients which may include crisis intervention, advocacy, medication monitoring, transportation assistance, financial budgeting,housing assistance,and referral and linkage to community resources as needed
Assist in helping clients achieve financial wellness and autonomy through supportive counseling and facilitating multiple care aspects (care coordination, information sharing, etc.)
Requirements
Associate’s degree in behavioral science or related field, or equivalent work experience as allowed/required by regulatory bodies
Manages a select population of eligible Home Health clients requiring supportive case management skills, determining client goals, assessing situations, and coordinating care within a multidisciplinary team.
Responsibilities
Determines client goals and needs
Assesses client situations
Works effectively with community resources and plans with clients for care and support
Provides continuity of care across the continuum by assessing clients, liaising with team members, coordinating, implementing clinical interventions, evaluating client outcomes
Acts as a clinical resource for the interdisciplinary team by providing information based on specialized theory and practice
Requirements
Current practicing registration as a Registered Nurse with the British Columbia College of Nurses and Midwives (BCCNM)
Three years’ recent clinical nursing experience in Home Health and case management or an equivalent combination of education, training and experience
Registered nurse with an Illinois nursing license who works remotely to manage member care, conduct outreach, analyze data, and support the Value Based Care Services team.
Compensation
The salary range for this role is $80,000.00 to $83,000.00 per year based upon experience.
Responsibilities
Manage case assignments including patient outreach via telephone, documentation, and monitoring for case progression and closure
Pull, sort, and analyze data to determine member eligibility for the Population Health management program
Coordinate and provide timely, effective, equitable, safe, and member‑centric care following HMO processes
Meet reporting and documentation standards while engaging in collaborative meetings with department staff and clients
Assist members in reaching wellness and health‑autonomy by addressing barriers, social determinants, member motivators, and psychosocial issues
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