Care Manager


Are you looking for an opportunity to use your clinical experience and passion to empower Medicare patients with chronic conditions to manage and improve their health? This position will allow you to join a team of forward-thinking primary care providers and population health experts who are embracing value-based care to achieve higher quality and higher value healthcare for patients statewide.

This position is responsible for the success of the Medicare Chronic Care Management (CCM) program within an independent primary care practice that is part of the Aledade Delaware Accountable Care Organization (ACO). The qualified candidate is a proactive and self-motivated clinical care manager who will help to develop and lead the CCM program within the practice. The candidate will be responsible for all aspects of the CCM program, including identifying and enrolling appropriate patients, developing and monitoring individual care plans in concert with the patient s primary care team, providing telephone-based care management to address the goals identified in the care plan, and all required documentation and billing. The successful CCM-enrolled patient will become activated in self-managing their health and will experience reduced unnecessary healthcare utilization before graduating from the program.


  • Review patient data within the ACO population health tool and Electronic Health Record (EHR) system to identify and enroll appropriate high-risk patients in CCM.
  • Work in partnership with primary care providers and each patient to establish a comprehensive goal-driven care plan.
  • Provide telephone-based support to patients enrolled in the CCM program, ensuring that patients are self-activated and achieving their healthcare goals with the result of improved health outcomes and decreased costs.
  • Coordinate care by serving as the advocate and resource for the patient, their family and their providers, building effective relationships in the community, (i. e., local hospitals, home health agencies, senior community services agencies, etc.) across the continuum of care to strengthen care coordination and safe care transitions across care settings.
  • Identify and graduate patients when goals have been achieved and patient is able to successfully self-manage their health.
  • Comply with Medicare and practice documentation and billing requirements.
  • Develop competency with Allscripts EHR.
  • Liaise with ACO field team members and care management experts to ensure care management initiative aligns with other ACO initiatives within the practice.


  • An experienced Medical Assistant with demonstrated clinical skills and knowledge
  • Demonstrated experience working with patients to better manage their health through disease self-management.
  • Experience with motivational interviewing and patient activation approaches
  • At least 3 years of experience, preferably in case management or care coordination for the elderly population across multiple care settings
  • Excellent computer skills and willingness to learn new software applications. Experience with Allscripts a plus
  • Familiarity with healthcare and community resources in southern Delaware a plus
  • Exceptional communication skills, both written and oral, ability to positively influence others with respect and compassion
  • Strong work ethic built on a foundation of productivity, collaboration and teamwork
  • Ability to manage multiple projects and activities with minimal supervision

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