Medical Case Manager

Henrietta Johnson Medical Center (HJMC) is a Federally Qualified Health Center with sites in Wilmington and Claymont, Delaware, providing an all-inclusive range of medical and dental services for the entire family. HJMC provides affordable access to integrated and coordinated family practice, women's health, dental, and behavioral health care services under one roof, with a team of caring, competent, and productive providers and staff focused on quality, compassionate, and coordinated care. About This Role The Medical Case Manager coordinates care for patients with complex medical, behavioral, and social needs across care settings. The role aligns clinical care, population health strategies, and payer requirements to improve outcomes, address social determinants of health, and reduce avoidable utilization and total cost of care. What You'll Do Performs comprehensive assessment of medical, psychosocial, functional, and social needs for assigned high-risk patients. Develops, updates, and monitors individualized care plans in collaboration with patients, caregivers when applicable, providers, and interdisciplinary team members. Coordinates transitions of care, specialty services, referrals, medication reconciliation support, and community-based services needed to stabilize health outcomes. Identifies and addresses barriers related to housing, food, transportation, financial hardship, behavioral health, and other social determinants of health through referral and follow-up. Monitors utilization patterns, high-risk indicators, and patient engagement to reduce avoidable emergency department visits, readmissions, and care fragmentation. Documents assessments, interventions, care plans, referrals, and outcomes accurately and promptly in the electronic health record. Collaborates with payers, clinical staff, social support resources, and external providers as permitted to support contract performance and continuity of care. Participates in case conferences, quality improvement activities, and compliance-related training and monitoring. What You Bring Current licensure as a Registered Nurse, Licensed Clinical Social Worker, or other appropriate licensed healthcare professional consistent with job duties. At least three years of experience in case management, care coordination, complex care, utilization management, or a related healthcare setting. Knowledge of chronic disease management, care transitions, and community resource navigation. Ability to assess risk, coordinate services, and document effectively in an electronic health record. Preferred Qualifications Case management certification or related advanced training. Experience in an FQHC, managed care, hospital care management, or high-risk patient program. Experience with value-based care, quality metrics, and interdisciplinary complex care workflows. This Role Is Grant-Funded This position is funded through Delaware's federal Rural Health Transformation Program grant, awarded through the Delaware Department of Health and Social Services. Although the RHT award covers a five-year project period, funding is approved and allocated annually, and continued employment in this role is contingent on annual grant reapproval. Compensation and Benefits This role offers a competitive salary based on experience and community health center pay standards in Delaware. Employees enjoy a range of benefits, including: Health Insurance (Medical / Dental / Vision) Long-Term Disability Employee Assistance Program (EAP) Short-Term Disability Option Equal Opportunity Employer Henrietta Johnson Medical Center is an equal opportunity employer. Questions About This Role Contact View email address on click.appcast.io or View email address on click.appcast.io. #J-18808-Ljbffr Henrietta Johnson Medical Center