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Chronic Disease Case Worker


  1. Coordinates patient care through ongoing collaboration with PCP, patient/family, community, and other members of the health care team.  Fosters a team approach and includes patient/family as active members of the team. Takes the lead in ensuring the continuity of care which extends beyond the practice boundaries.  Serves as liaison to acute care hospitals, specialists, and post-acute care services.
  2. Provides patient self-management support with a focus on empowering the patient/family to build capacity for self- care.
  3. Systematically monitor patient progress and treatment plans, report changes of symptoms, side effects or complications.
  4. Provides follow-up with patient/family when patient transitions from one setting to another.  Completes timely post-hospital follow-up:   Medication reconciliation, PCP or specialist follow-up appointment, assess symptoms, teach warning signs, review discharge instructions, coordination of care, and problem solve barriers.
  5. Maintains required documentation for all care management activities via the use of a web-based data entry system.
  6. Works with practice to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance care management and Patient Centered Medical Home delivery of care model.
  7. Perform all other duties as assigned.


Certified Medical Assistant /Certified Nurse’s Assistant/Licenses Practical Nursing Degree/Dietician/Social Services or something similar  


  • Critical thinking skills and ability to analyze complex data sets.
  • Ability to communicate effectively and articulate both orally and in writing.
  • Proficient with Microsoft Office Suite or related software.
  • Ability to work well with individuals of diverse socioeconomic, cultural, and intellectual backgrounds.


  • Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education.
  • 2-3 yeas of previous experience in social services or related fields.
  • Bi-lingual preferred.