Hospital Case Manager

Job Description

Description:

Join the Team at PedIM Healthcare!

Delivering exceptional care, together.  

Who We Are  

PedIM Healthcare is the first private medical office of its kind in Citrus County – offering top-quality care for children, adults, and seniors all under one roof. We provide pediatrics, adult internal medicine, family practice, geriatrics, women’s care, medical weight-loss, sleep-medicine services and more. 

Our dedicated, community-focused team is committed to excellence, pride in service, and making a real difference for patients and families across Citrus County.
 

Why Work With Us?

• A broad, multi-discipline practice where you can grow: pediatrics, internal medicine, weight-loss & sleep medicine specialties.
• A values-driven environment: we listen, we help, we understand—and we care.
• Community-oriented and recognized: voted “best of the best” in the region.
• Opportunity to make a meaningful impact by supporting patients over their full life span—from children to seniors.
• A workplace committed to employee development and delivering holistic care.

The Role

We are seeking a proactive and compassionate Hospital Case Manager to join our Primary Care team!

The Hospital Case Manager supports our primary care practice and value-based care programs, Medicare and Medicare Advantage populations. You will be responsible for hospital rounding on behalf of assigned primary care providers, coordinating care for patients who are admitted as inpatients, communicating clinical updates to the provider team, and supporting safe discharge planning and continuity of care.

This role focuses on coordinating care transitions, supporting high-risk patients, and reducing avoidable hospital utilization through proactive follow-up and care coordination.

What You'll Do:

• Monitor hospital admissions, discharges, and ED visits for assigned patients
• Conduct timely post-discharge outreach and care coordination
• Schedule and support follow-up appointments with primary care and specialists
• Perform medication reconciliation after hospital discharge
• Identify high-risk patients and provide targeted care management
• Coordinate home health, rehab, DME, and community resources
• Support quality measures related to readmissions, care transitions, and chronic disease management
• Document care coordination activities in the EHR
• Collaborate with providers, care teams, and hospital partners

Qualities That Make You A Great Fit:

Required

• RN, LPN, or Social Worker (BSW/MSW) with active state license
• 2+ years of experience in case management, hospital discharge planning, or ambulatory care
• Strong communication and organizational skills

Preferred

• Experience with value-based care, ACOs, or Medicare Advantage
• Case Management certification (CCM, ACM)
• Familiarity with quality metrics and population health workflows

What Success Looks Like:

• Timely post-discharge follow-up
• Reduced hospital readmissions and ED utilization
• Improved patient engagement and continuity of care

Benefits Available To You:

Joining our team means more than just a job—it means access to benefits designed to support your health, well-being, and work-life balance.

• Health coverage + Sick-N-Well membership
• Health Savings