Hospital Case Manager at PedIM Healthcare – Lecanto, Florida

We are seeking a Hospital Case Manager to support our primary care practice and value-based care programs, Medicare and Medicare Advantage populations. The Case Manager 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.

Why Join Us?

• Team-based, patient-centered environment
• Focus on quality and outcomes, not volume
• Opportunity to make a measurable impact on patient care

Key Responsibilities

• 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

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

PM20