The Longitudinal Care Manager provides ongoing care coordination and management for patients over time, ensuring continuity of care, optimal health outcomes, and appropriate utilization of services. This role supports patients across the continuum of care following initial assessments through regular monitoring, plan adjustments, and collaboration with multidisciplinary teams. Key Responsibilities:

• Manage a caseload of patients longitudinally, tracking health status, progress, and care needs.
• Update and adjust individualized care plans based on patient condition, clinical goals, and evolving needs.
• Coordinate with physicians, specialists, community resources, and other care providers to ensure comprehensive care delivery.
• Conduct regular patient outreach via phone or telehealth to monitor health, provide education, and reinforce care plans.
• Identify barriers to care and implement strategies to address social, behavioral, or medical needs.
• Document all patient interactions, care plan updates, and progress notes accurately in the electronic health record (EHR).
• Facilitate smooth transitions between stages of care (initial, palliative, hospice) when appropriate.
• Serve as a resource and advocate for patients and their families.

Qualifications:

• Current NYS RN license
• Experience in case management, care coordination, or similar clinical roles.
• Knowledge of chronic disease management, utilization management, and patient-centered care.
• Knowledge of D-SNP, Medicare, and Medicaid programs and eligibility criteria.
• Strong communication, problem-solving, and organizational skills.
• Ability to work independently and manage multiple patients effectively.

Preferred:

• Experience with telephonic care management or remote patient monitoring.
• Familiarity with EHR systems and care management software.
• Previous experience across the continuum of care (initial, longitudinal, palliative, hospice).

Remote Skills: Case Management, Chronic Disease, Communication Skills, Cross-Functional, Disease Prevention and Control, Health Education, Health Plan, Hospice Care, Medicaid, Medical Record System, Medicare, Organizational Skills, Patient Care, Problem Solving Skills, Quality of Care, RMON, Registered Nurse (RN), Systems Administration/Management, Telehealth, Training/Teaching, Utilization Management About the Company: Phaxis We stand for PERSEVERANCE, as we refuse to quit when the journey gets tough. Your gold is our mission, and we search day and night to find it. Company Size: 50 to 99 employees Industry: Staffing/Employment Agencies Founded: 2002 Website: https://phaxis.com/