Temporary Chronic Care Manager (Primary Care - Rural Health)

Position Title: Chronic Care Manager (Primary Care - Rural Health)Position Type: Temporary Full Time; 35 Hours Weekly; this is a grant funded position available through October 31, 2026. (Potential for Continuation)Benefits Eligible: YesLocation: Toms River, NJDepartment: Primary Care - Rural HealthSalary: $25.00 - $27.00 hourlyResponsibilities:Develop, implement, and regularly update individualized care plans for patients with chronic conditions (e.g., diabetes, hypertension, COPD, heart disease)Conduct comprehensive patient assessments, including medical, behavioral, and social determinants of healthProvide ongoing care coordination, including scheduling follow-ups, managing referrals, and ensuring adherence to treatment plansMonitor patient progress through regular outreach (phone, telehealth, or in-person visits) and adjust care plans as neededEducate patients and caregivers on disease management, medication adherence, lifestyle changes, and preventive careServe as a liaison between patients, primary care providers, specialists, hospitals, and community-based organizationsIdentify and address barriers to care, particularly those affecting rural populations (e.g., transportation, limited provider access, financial constraints)Support transitions of care, including hospital discharge follow-ups and coordination with post-acute servicesMaintain accurate and timely documentation in the electronic health record (EHR) in compliance with regulatory and organizational standardsParticipate in quality improvement initiatives and population health management strategiesWork Environment & Travel:Combination of clinic-based work, remote care coordination, and occasional field visitsTravel within rural regions of Ocean County New Jersey may be requiredRequirementsBachelor's degree in Nursing, Social Work, Public Health, or a related field preferred. Minimum of 2-3 years of experience in care management, chronic disease management, or primary careStrong understanding of chronic care models and population health principlesExperience working with underserved or rural populations is preferredExcellent communication, organizational, and problem-solving skillsProficiency in EHR systems and care management platformsAbility to work independently and as part of a multidisciplinary teamPreferred Skills:Familiarity with telehealth tools and remote patient monitoringKnowledge of Ocean County NJ community resources and social service networksBenefitsBirthdays off12 Paid HolidaysSick DaysPersonal DaysDays Accrued VacationMedical/Dental/VisionCompany paid Life Insurance and Long-Term Disability403B Plan with Company MatchOpportunities for training/education/Continuing Education CreditsOpportunities for Public Loan ForgivenessOpportunities for Tuition Discounts from Participating Institutions