• Currently certified or registered as a medical assistant CMA or RMA, licensed as a licensed practical nurse/licensed vocational nurse, registered nurse, or social worker including: LMSW and LSW, registered nurse, have a degree in social work including MSW, BSW have a degree in case management or relevant work experience in the field of social work or case management.
  • Minimum one-year health care experience. Community/home health, medical office setting, geriatric care preferred or general medical. Prior case management experience a plus.
  • Complies with accepted professional standards and practice.
  • Possesses and maintains good physical stamina and mental health. Has presented a pre-employment health clearance.
  • Is self-directed with the ability to work with little supervision; has good organizational skills.
  • Is flexible and cooperative in fulfilling role obligation and enjoys working with chronically ill patients.
  • Comfortable working with technology to include but not limited to computers and cell phone




  1. Develops and manages patient-centered comprehensive care plan for chronic care management while under supervision of medical provider.
  2. Enrolls and manages patients in all Guardian Wellness programs appropriate and eligible including but not limited to Annual Wellness Visits(AWV), Chronic Care Management(CCM) and Remote Patient Monitoring(RPM) and Advanced Care Planning(ACP).
  3. Provides accurate and timely documentation consistent with CMS and Chronic Care Management guidelines including in software, daily activity reports and in provider electronic medical records as required.
  4. Assesses and provides patient’s education and information pertinent to diagnosis and care plan goals.
  5. Participates in coordination of home health services, appropriately reporting the need for disciplines (HHA, OT, PT, MSW, ST, Dietitian, Pharmacist) to the medical providers office staff/or Administrator.
  6.  Uses equipment and supplies effectively and efficiently.
  7.  Participates in personal professional growth and development.
  8.  Participates in public relations and community activities that promote the Agency’s role as an effective member of the health care delivery system.
  9.  Coordinates with others involved with the patient and relays concerns to the provider when needed
  10.  Other aspects and demands of the job not listed above:


The above statements are intended to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.




  1. Work remotely and in the clinic as needed and requested by provider clinic.
  2. This position has been designated Class I (see policy 9-1). Employees performing Class I duties may be involved in potential exposure to blood borne pathogens. All Class I employees is offered Hepatitis B vaccination at no expense to the employee.




  1. Visual/hearing ability sufficient to comprehend written/verbal communication.
  2.  Ability to perform tasks involving minimal physical activity, sitting for long period of time minimal lifting and extensive bending and standing.
  3.  Ability to deal effectively with stress.




Agency personnel are expected to participate in appropriate continuing education as may be requested and/or required by their immediate supervisor. In addition, agency personnel are expected to accept personal responsibility for other educational activities to enhance job related skills and abilities. All agency personnel must attend mandatory educational programs.

Must have a laptop with Windows 10 Professional or Mac and a cell phone

Apply for position now