Job Description
RN Care Manager – Wholecare Program
Location: New Castle, DE or Kent County (Field-Based + Remote)
Schedule: 3 Days Field / 2 Days Remote
Type: Full-Time | Travel Required (up to 30 miles one way)
Start Date: ASAP (Field visits start Week 1)
Role Overview
The Care Manager serves as the single point of contact for members enrolled in DSHP Plus LTSS, coordinating all aspects of their care across health, social, and community services. The role involves frequent travel to members’ homes, nursing facilities, and community settings to conduct face‑to‑face assessments and ongoing telephonic follow‑ups.
Key Responsibilities
Conduct assessments, develop, implement, and evaluate care plans for members with chronic and complex needs.
Coordinate services across physical, behavioral, long‑term care, and social supports.
Facilitate care transitions (e.g., hospital to home, nursing facility to community).
Educate members and caregivers on health care needs, benefits, resources, and available services.
Collaborate with interdisciplinary teams, including Member Advocates, ICT, and discharge planners.
Connect members to community resources and special programs (e.g., chronic condition management, behavioral health, complex case management).
Monitor effectiveness of care plans and adjust as needed.
Document all case management activities in the electronic health record.
Ensure compliance with HIPAA, company, state, and federal guidelines.
Qualifications
Required
Bachelor’s degree in social work or related field + 3 years relevant experience, OR
Master’s degree in social work or related field + 1 year relevant experience, OR
RN/LPN + 2 years relevant experience, OR
High school diploma + 3 years qualifying case management experience with aging or special populations.
Preferred
Home clinical or case management experience
CCM, LBSW, LMSW, or LCSW licensure
Experience with HIV/AIDS, behavioral health, or developmental disabilities populations