Community Team Care Manager - CKD

Job Summary This advanced role serves as both the clinical lead and an individual contributor within an integrated community care team (ICCT), functioning as the team captain of a dedicated community pod. The community pod assumes responsibility for the care of an assigned panel of members within a particular region, ensuring care continuity and focused support for their total care needs. The Community Team Care Manager (CTCM) is accountable for overseeing the panel of assigned members through delegated care plan management delivered by Community Health Workers (CHWs) and provides direct services to a small caseload of the most complex members. The community pod team is responsible for managing both longitudinal and episodic care needs of members across the care continuum. In addition to clinical case management, the CTCM acts as the clinical escalation path for the CHWs, ensuring timely and effective resolution of complex care needs. The CTCM sets the daily tone for the pod, leading morning huddles, driving performance to achieve key organizational outcomes including member engagement, completion of annual wellness exams, care gap closure, utilization management & readmission reduction, and enrollment in the Primary Care Provider (PCP) program. This position requires strong leadership skills, experience directing matrixed teams, and a high degree of competency in delegation, accountability, and the supervision of allied health professionals. The CTCM further supports population health initiatives through regular integrated care population health meetings and quarterly care plan oversight visits with the community health workers for their assigned members. Success in this role will be measured by value-based care metrics, including member engagement with the healthcare team, improved utilization management outcomes related to admissions, readmissions, and emergency department visits, and performance on quality measures related to preventive care and chronic condition management. Duties and Responsibilities Serve as the clinical and operational lead for a community pod, overseeing community health workers in the delivery of both longitudinal and episodic care management for members. Be a part of Transitions of Care team to ensure safe and effective discharge planning, promoting continuity of care back into the community and reducing avoidable hospital admissions, readmissions and unnecessary emergency department visits through proactive coordination and follow‑up. Oversee and coordinate care for an assigned panel of members within a specific region, ensuring comprehensive and consistent support for all regional members. Provide direct case management for a small panel of the most complex members, conducting comprehensive assessments and developing person‑centered care plans (PCCPs) that prioritize and address health goals in collaboration with members, families, and the interdisciplinary team. Conduct assessments and develop person‑centered care plans (PCCPs) with delegated care plan tasks and oversight to CHWs, ensuring accountability and support through regular communication, supervision, and coaching. Lead daily morning huddles to review team activities, set priorities, and drive accountability towards achieving key performance indicators—including member engagement, annual wellness exams, care gap closures, appropriate utilization, and PCP program enrollment. Conduct quarterly care plan oversight visits for assigned members, ensuring high‑quality, person‑centered care and adherence to evidence‑based clinical standards. Act as the clinical escalation path for CHWs, providing guidance, support, and intervention when member conditions or care needs exceed established parameters. Participate in and facilitate population health and regular panel review meetings to track progress, identify trends, and implement interventions. Collaborate regularly with primary care providers, specialists, health plan programs, AbsoluteCare services, and community resources to ensure comprehensive, coordinated care for all members under pod oversight. Ensure all care plans, documentation, and communications meet agency requirements, internal protocols, accreditation standards, and regulatory guidelines. Support member engagement and transitions of care, proactively addressing barriers to treatment adherence and access to resources. Utilize a range of evidence‑based clinical interventions, including motivational interviewing, trauma‑informed care, harm reduction, and teach‑back methods. Facilitate internal resources to other AbsoluteCare programs including Center Based Primary Care, pharmacy, behavioral health consultant (BHC), Immediate Care Area (ICA), etc. to meet member needs. Monitor and report on pod and individual KPIs, using data to drive quality improvement and member outcomes. Maintain up‑to‑date documentation in electronic health records, ensuring all member interactions and care plan changes are captured within 1 business day. Promote a collaborative, accountable, and member‑focused team culture through effective communication and leadership. Actively participate in required meetings, training, and organizational initiatives as a team captain and subject matter expert. This position is 80% Remote with the requirement of local travel and only manages patients with Chronic Kidney Disease. Minimum Qualifications Licensed RN by the state in which practicing and abide by all laws, regulations, and requirements. Highly desirable preference given to RN candidates with extensive experience of medical and behavioral case management in the community. Candidate with CCM a plus. LMSW with similar job experience and certifications may be considered. In lieu of CCM credential, 3+ integrated case management experience. Must obtain CCM within 24 months of hire date. 3+ years of experience serving medically complex populations with behavioral health, trauma, substance use, and socioeconomic barriers in office, home, and community‑based settings. Experience leading, supervising, or directing allied health team members and/or community health workers strongly preferred. Demonstrated ability to work effectively in matrixed team environments, with strong skills in delegation, supervision, and accountability. Experience managing panels, overseeing care plans, and providing direct clinical care for complex cases. Strong understanding of value‑based outcomes, quality programs (NCQA, PCMH, HEDIS), and performance management. Excellent computer skills (Microsoft Office Suite, EMR systems) and written/oral communication abilities. Active, unencumbered driver’s license, automobile insurance, and reliable transportation required. Working Conditions This job operates in the community and within a professional office environment. This role requires reliable transportation to commute back and forth between member homes and office; and routinely uses general office equipment. This role requires a dedicated, quiet workspace with the ability to adhere to HIPAA and other privacy policies. A reliable and high‑speed Wi‑Fi connection or home internet is required to perform the essential functions of this role. Physical Requirements Ability to communicate clearly and exchange accurate information constantly. Ability to remain stationary for long periods of time. Constantly operates computer, keyboard, copy and fax machine, phone, and other general office equipment. Operates a personal motor vehicle. Ability to occasionally move objects up to 20 lbs. Direct Reports None. #J-18808-Ljbffr AbsoluteCare