Care Management Specialist-LPN

Work from Home. Improve Patient Health. Make a Difference.

Family Health Centers, Inc. is seeking compassionate and organized Licensed Practical Nurses (LPNs) to join our team as Care Management Specialists.

This position supports patients through care management, chronic disease management, care coordination, transitional care services, preventive care initiatives, and population health programs designed to improve patient outcomes while reducing avoidable hospitalizations and emergency room visits.

This is a hybrid position with approximately 80% remote work and occasional in-clinic presence for meetings, training, quality initiatives, and patient support activities.

Position Summary

As a Care Management Specialist, you will work directly with patients, providers, and interdisciplinary care teams to improve health outcomes, close care gaps, coordinate services, and support patients in achieving their healthcare goals.

Essential Responsibilities

• Conduct patient outreach and follow-up calls
• Enroll eligible patients into care management programs
• Coordinate care following hospital, emergency room, and skilled nursing facility discharges
• Assist with scheduling preventive care visits and Annual Wellness Visits (AWVs)
• Develop, implement, and update patient-centered care plans
• Support patients with chronic disease management, including diabetes, hypertension, heart disease, COPD, asthma, and other chronic conditions
• Monitor patient progress and assist with achieving care goals
• Coordinate referrals and follow-up appointments
• Connect patients with community resources and support services
• Identify barriers to care and assist patients in overcoming obstacles to treatment
• Document patient interactions and services in the electronic health record (EHR)
• Collaborate with providers, nurses, behavioral health staff, pharmacists, and care teams to improve patient outcomes and close care gaps