Program Manager, System of Care

The Role:

As the Program Manager, System of Care (SOC), you will play a pivotal role in building and leading an integrated, community-based network of behavioral health, social, and medical services. This position focuses on fostering strong partnerships with healthcare providers, social service agencies, schools, law enforcement, and other key stakeholders to ensure individuals and families receive comprehensive, coordinated support. You will champion collaboration and resource integration, ensuring that everyone in need can access services through a seamless “no wrong door” approach.

Your Impact:

• Collaborate with interdisciplinary teams to develop, implement, and monitor individualized transition of care plans.
• Assess patients and caregivers needs, preferences, and goals during care transitions.
• Coordinate and schedule follow-up appointments, tests, and procedures as required.
• Serve as the primary point of contact for patients and families during transitions, providing clear instructions and answering questions.
• Communicate relevant patient information to receiving healthcare providers to ensure continuity of care.
• Work with community resources, home health agencies, and other external partners to secure necessary services and support.
• Educate patients and their families on disease management, medication adherence, and self-care during the transition process.
• Provide resources and referrals to address social determinants of health, such as transportation, housing, or financial assistance
• Conduct post-discharge follow-up calls to assess patient status, address concerns, and reinforce care plans.
• Monitor high-risk patients closely to prevent hospital readmissions and emergency room visits.
• Document all care coordination activities in the patient’s electronic medical record (EMR) accurately and timely
• Participate in quality improvement initiatives aimed at enhancing the transition of care processes.
• Analyze data related to care transitions and contribute to performance improvement strategies.
• Perform other duties and support deliverables as assigned by the organization to help drive our Vision, fulfill our Mission, and abide by our Organization’s Values.

Your Credentials:

• Bachelor's degree in nursing, social work, healthcare administration, or a related field.
• Minimum of 2-3 years of experience in care coordination, case management, or a related healthcare role.
• Experience in transitions of care is highly desirable.
• Current RN, LCSW, or related professional licensure is preferred. Case Management Certification (CCM, ACM) is an advantage.
• Strong knowledge of care coordination principles, hospital discharge processes, and community resources.
• Excellent communication, organizational, and problem-solving skills.
• Ability to work independently and as part of a multidisciplinary team.
• Proficiency in using electronic medical records (EMR) systems and other care management software.

Job Type: Full-time

Pay: $65,000.00 - $75,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• Day shift
• Monday to Friday

Work Location: Hybrid remote in Roseburg, OR 97470

Salary : $65,000 - $75,000