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: Yes Location: Toms River, NJ Department: Primary Care - Rural Health Salary: $25.00 - $27.00 hourly

Responsibilities

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 health. Provide ongoing care coordination, including scheduling follow-ups, managing referrals, and ensuring adherence to treatment plans. Monitor patient progress through regular outreach (phone, telehealth, or in-person visits) and adjust care plans as needed. Educate patients and caregivers on disease management, medication adherence, lifestyle changes, and preventive care. Serve as a liaison between patients, primary care providers, specialists, hospitals, and community-based organizations. Identify 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 services. Maintain accurate and timely documentation in the electronic health record (EHR) in compliance with regulatory and organizational standards. Participate in quality improvement initiatives and population health management strategies. Work Environment & Travel: Combination of clinic-based work, remote care coordination, and occasional field visits. Travel within rural regions of Ocean County New Jersey may be required. Bachelor’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 care. Strong understanding of chronic care models and population health principles. Experience working with underserved or rural populations is preferred. Excellent communication, organizational, and problem-solving skills. Proficiency in EHR systems and care management platforms. Ability to work independently and as part of a multidisciplinary team. Preferred Skills: Familiarity with telehealth tools and remote patient monitoring. Knowledge of Ocean County NJ community resources and social service networks. Birthdays off 12 Paid Holidays Sick Days Personal Days Days Accrued Vacation Medical/Dental/Vision Company paid Life Insurance and Long-Term Disability 403B Plan with Company Match Opportunities for training/education/Continuing Education Credits Opportunities for Public Loan Forgiveness Opportunities for Tuition Discounts from Participating Institutions