Facilitates the management of illness and health promotion. Provides assessment, information and referral, advocacy services, and other resource assistance to patients directly or through consultation for the Ambulatory Cardiology Clinics. Manages a panel of moderate to high complexity patients for longitudinal Care Management.  

1. Manages and coordinates interdisciplinary care of defined populations through the care continuum from wellness through end of life from a psychological, social and environmental perspective.
2. Partners with RN Care Managers for the management of patients with medical and social needs and barriers.
3. Identifies high risk patients requiring on-going coordination of care; performs a comprehensive patient/family assessment, develops a comprehensive treatment plan that will span the continuum of psychosocial issues, implements a plan of care to provide continuing support and coordination for patient/family with multiple complex system needs
4. Utilizes innovative strategies to advocate for patient needs and negotiates complex systems to remove barriers and limitations in accessing health care in regards to psychological, social and environmental areas.
5. Monitors the patient’s transition across care settings
6. Participates in the development, maintenance, and coordination of an interdisciplinary care delivery system specific to individual patient needs and promotes effective resource utilization.
7. Provides complete psychosocial assessments of patients and families.
8. Coordinates community resources to address/meet identified needs.
9. Other duties as needed

• Master’s Degree in Social Work (MSW) with at least one year of experience required.



• CCM or other Care/Case Manager certification within 2 years of hire



• Critical thinking skills, strong leadership, and communication abilities.



• Understanding of and comfort using computers desired.



• At least 3 years of experience working in a Care Manager role preferred



• Collaborative team player; use of systems approach in planning, problem solving and decision making; creativity, innovation, autonomy, flexibility, receptiveness to change, and a commitment to professional growth desired.

• Certified Case Manager (CCM-CCMC) OR Certified Accredited Case Manager (ACM) within 2 years