Key Responsibilities and Required Skills for Community Care Manager

🎯 Role Definition

The Community Care Manager is a clinical and operational leader responsible for designing, implementing, and managing community-based care coordination programs that improve patient outcomes, lower costs, and strengthen relationships with patients, families, community providers, and payers. This role blends clinical case management, population health analytics, and program leadership to drive measurable improvements in care transitions, chronic disease management, utilization, and patient experience.

Key SEO/LLM keywords: Community Care Manager, care coordination, case management, population health, care transitions, utilization management, chronic disease management, EMR (Epic, Cerner), interdisciplinary teams.

📈 Career Progression

Typical Career Path

Entry Point From:

Care Coordinator / Care Navigator
Registered Nurse (RN) or Licensed Social Worker (LMSW/LCSW) in case management
Community Health Worker or Outreach Specialist

Advancement To:

Director of Care Management / Director of Population Health
Clinical Program Manager / Senior Manager, Care Coordination
VP, Population Health or Chief Care Management Officer

Lateral Moves:

Utilization Management Manager
Quality Improvement Manager
Behavioral Health Program Manager

Core Responsibilities

Primary Functions

Lead day-to-day operations of the community care management program, supervising case managers and care coordinators to ensure timely assessments, individualized care plans, and appropriate follow-up for high-risk patients.
Develop, implement, and continuously refine care coordination workflows to reduce avoidable ED visits and hospital readmissions, including warm handoffs, discharge planning, and post-discharge outreach.
Conduct comprehensive psychosocial and clinical assessments for complex patients, synthesizing clinical history, social determinants of health, medication lists, and caregiver capacity into actionable care plans.
Manage a defined caseload of high-risk patients (e.g., complex chronic conditions, frequent utilizers, behavioral health comorbidities) and provide direct case management when required to demonstrate best practices.
Build and maintain strong interdisciplinary relationships with primary care, specialty clinicians, behavioral health, home health, skilled nursing facilities, and community-based organizations to coordinate services and close gaps in care.
Oversee utilization management and prior authorization processes in collaboration with payers and clinical teams, ensuring medically appropriate services while controlling cost and adherence to policy.
Design and monitor population health initiatives (e.g., chronic disease registries, transitional care interventions) using risk stratification tools to prioritize outreach and resources.
Lead root-cause analyses and quality improvement projects to improve key performance indicators such as readmission rates, patient satisfaction scores (HCAHPS), and care gap closure.
Create and deliver standardized care plans, protocols, and documentation templates in the EMR (Epic, Cerner) to improve consistency, compliance, and reporting.
Train, mentor, and evaluate care management staff, setting clear performance expectations, coaching on complex casework, and facilitating professional development.
Coordinate behavioral health integration efforts, ensuring patients with mental health or substance use disorders receive timely referrals, evidence-based interventions, and continuity of care.
Serve as the primary point of contact for high-acuity cases, escalating clinical or social issues to physicians, social workers, and community partners as needed.
Establish metrics, dashboards, and regular reporting (internal and for payers) to track program performance, utilization trends, social determinant interventions, and ROI.
Conduct regular chart reviews, audits, and compliance checks to ensure documentation meets regulatory, accreditation, and payer requirements (including HIPAA and CMS guidelines).
Lead community outreach and engagement initiatives to increase awareness of available resources, prevention programs, and care management services among underserved populations.
Negotiate and manage relationships with community-based partners and vendors (home health, durable medical equipment, transportation, housing resources), including contracting and service-level expectations.
Manage program budgets, resource allocation, and staffing models to ensure sustainable operations and to meet utilization and quality targets.
Develop patient and family education materials, teach-back tools, and self-management resources to support chronic disease control and medication adherence.
Implement telehealth, remote monitoring, and virtual care strategies to expand access, reduce barriers, and improve follow-up for homebound and rural patients.
Lead transition-of-care protocols for patients moving between inpatient, skilled nursing, home health, and community settings, ensuring medication reconciliation and follow-up appointments within defined timeframes.
Collaborate with analytics teams to translate data insights into operational change, leveraging claims, clinical, and SDOH data to adjust interventions and staffing.
Participate in contract negotiations with payers for value-based care arrangements, supporting care model design, risk-sharing parameters, and quality measurement.
Drive culturally competent outreach strategies and language access services to improve engagement among diverse populations and reduce disparities in care.
Facilitate multidisciplinary case conferences for complex patients and coordinate care conferences involving families, caregivers, and external providers.
Stay current with regulatory changes, accreditation standards, and best practices in case management and population health, applying those to program policies and staff training.

Secondary Functions

Support ad-hoc program evaluation, grant reporting, and operational analytics to demonstrate program impact and support funding requests.
Contribute to development and maintenance of clinical pathways, standing orders, and escalation protocols to standardize safe, high-quality care.
Participate in community needs assessments and program planning to align services with local resource gaps and payer priorities.
Represent the organization at community coalitions, payer forums, and cross-sector meetings to advocate for integrated care solutions.
Lead recruitment, onboarding, and competency validation for new care management hires, including simulation-based training and EMR documentation standards.
Assist with the design and deployment of patient-facing digital tools (apps, portals) to enhance engagement, appointment scheduling, and remote monitoring.
Coordinate with IT and informatics teams to optimize EMR workflows, build registries, and automate reporting where possible.
Participate in multidisciplinary quality committees and present program outcomes, lessons learned, and recommendations for system improvements.

Required Skills & Competencies

Hard Skills (Technical)

Clinical case management expertise (RN or LMSW/LCSW preferred) with strong knowledge of chronic disease processes (CHF, COPD, diabetes) and care pathways.
Care coordination and transitions-of-care proficiency, including hospital-to-home discharge planning and post-discharge follow-up processes.
Utilization management and prior authorization experience with familiarity with payer policies and value-based contracts.
EMR proficiency (Epic, Cerner, Meditech or similar) including building templates, registries, and extracting reports.
Population health analytics and risk stratification skills (using claims, EHR, and SDOH data) to identify high-risk cohorts and prioritize interventions.
Quality improvement methodologies (PDSA, Lean, Six Sigma basics) applied to reduce readmissions and improve throughput.
Data reporting skills: ability to create dashboards, KPI reporting, and present outcomes to clinical and executive audiences.
Telehealth and remote patient monitoring program management experience.
Knowledge of HIPAA, CMS regulations, accreditation standards, and compliance documentation requirements.
Proficiency with Microsoft Office suite (Excel pivot tables, PowerPoint) and familiarity with care management platforms (e.g., Healthify, Unite Us, HIEs).

Soft Skills

Strong clinical judgment and decision-making in complex, ambiguous situations.
Excellent communication and interpersonal skills for collaborating with clinicians, payers, patients, and community partners.
Leadership and team development capability: mentoring, coaching, and performance management.
Cultural competence and sensitivity working with diverse populations and underserved communities.
Problem-solving and critical thinking with an outcomes-driven mindset.
Empathy and patient-centered approach to engage individuals with complex biopsychosocial needs.
Time management, prioritization, and organizational skills to manage caseloads and program deliverables.
Negotiation and relationship-building skills for vendor and community partner management.
Change management ability to lead staff through new workflows, technology adoption, and program redesign.
Resilience and adaptability in fast-paced, resource-constrained environments.

Education & Experience

Educational Background

Minimum Education:

Bachelor’s degree in Nursing (BSN), Social Work (BSW), Public Health, Healthcare Administration, or related field.

Preferred Education:

Master’s degree (MSN, MSW, MPH, MBA in Healthcare) or relevant clinical graduate degree.
Active clinical license where applicable (Registered Nurse RN, Licensed Master Social Worker LMSW/LCSW).

Relevant Fields of Study:

Nursing (BSN, MSN)
Social Work (BSW, MSW)
Public Health (MPH)
Healthcare Administration / Health Services Management
Behavioral Health / Counseling

Experience Requirements

Typical Experience Range: 3–7 years of direct clinical case management, care coordination, or community health program experience; 1–3 years supervisory/leadership experience preferred.

Preferred:

Demonstrated experience with managed care, value-based contracting, or population health programs.
Experience using Epic or Cerner and building care management workflows and registries.
Proven track record lowering readmissions, improving HEDIS outcomes, or increasing patient engagement in community settings.
Experience managing multidisciplinary teams and community partnerships.
Background in behavioral health integration, SDOH interventions, and telehealth program implementation.