Clinical Support Specialist / Care Manager – Primary & Palliative Care
CCHC is seeking a dependable, compassionate, and highly organized Clinical Support Specialist/Care Manager to join our Primary and Palliative Care team.
This position is ideal for a CMA/RMA, LPN, or RN who enjoys building relationships with patients and coordinating care beyond the traditional office visit. The role focuses on supporting patients with complex medical needs, chronic conditions, and barriers to care through care management, patient education, clinical support, and coordination between providers and healthcare settings.
This position includes local travel to patients' homes. Home visits may include phlebotomy, vaccinations, patient assessments, and other clinical services appropriate to the employee's licensure, certification, and scope of practice. Approved work-related mileage is reimbursed at the current IRS standard mileage rate in accordance with organizational policy.
What You'll DoCare Management & Patient Support
- Coordinate care for patients with complex and chronic medical conditions, including diabetes, COPD, CHF, and hypertension.
- Develop and support individualized patient care plans.
- Conduct telephone, in-person, and home-based patient follow-up.
- Identify barriers to care, including transportation, financial concerns, health literacy, and access to community resources.
- Follow up with patients after hospitalizations and emergency department visits to support safe transitions of care.
- Perform medication reconciliation and provide medication and disease-management education.
- Coach patients and caregivers on symptom management, healthy lifestyle changes, and self-management skills.
- Utilize motivational interviewing and patient-centered communication techniques.
- Serve as a liaison among patients, caregivers, Primary Care Providers, the Palliative Care team, specialists, hospitals, and community resources.
- Participate in monthly care management and interdisciplinary meetings.
Clinical Support & Home Visits
- Travel locally to patients' homes to provide assigned clinical services.
- Perform blood draws and specimen collection for homebound patients.
- Administer vaccines and routine immunizations as ordered and within scope of practice.
- Assess patient needs and appropriately communicate or escalate clinical concerns.
- Coordinate referrals, diagnostic testing, follow-up appointments, and other patient care needs.
- Maintain accurate and timely documentation in the electronic health record (EHR).
Patient Communication & Care Coordination
- Review and respond to patient telephone calls and electronic messages according to established protocols and scope of practice.
- Provide patients and caregivers with clear education regarding care plans, medications, symptom management, and next steps.
- Assist with new patient enrollment and education.
- Prepare patient charts prior to provider visits, including medication reconciliation and review of available medical records.
- Identify gaps in care, missing specialist documentation, advance directive needs, and outstanding follow-up items.
- Assist with provider scheduling and coordination of patient appointments.
- Help facilitate continuity of care between hospitals, specialists, primary care, palliative care, and the patient's home.
Qualifications
- Graduate of an accredited Medical Assistant (CMA/RMA), Licensed Practical Nurse (LPN), or Registered Nurse (RN) program.
- Current applicable clinical certification or licensure in good standing.
- BLS certification required.
- Minimum of 2 years of clinical experience preferred.
- Experience in primary care, palliative care, oncology, home health, hospice, chronic care management, or care coordination is highly preferred.
- Proficiency in phlebotomy/venipuncture.
- Strong EHR navigation and documentation skills.
- Excellent telephone communication and patient education skills.
- Strong organizational, time-management, and problem-solving abilities.
- Ability to work independently while collaborating effectively with an interdisciplinary healthcare team.
- Compassionate and professional approach to caring for patients with complex, chronic, or serious illnesses.
Travel Requirements
- Local travel to patients' homes is required.
- Reliable transportation is required.
- Must be comfortable providing clinical services in a variety of patient home environments.
- Approved business mileage is reimbursed at the current IRS standard mileage rate in accordance with organizational policy.
Why Join Our Team?
This is an opportunity to make a meaningful impact on patients who benefit from additional support between traditional healthcare visits. You'll work closely with Primary and Palliative Care providers to help patients navigate their care, manage chronic conditions, address barriers, and remain safely supported in their homes whenever possible.
If you are a CMA/RMA, LPN, or RN who enjoys patient education, care coordination, and developing meaningful relationships with patients and families, we encourage you to apply.
Application Question(s):
- If you do not currently reside in the New Bern, NC or surrounding area what are your plans for relocation?
Education:
Work Location: In person
