The Longitudinal Care Manager provides ongoing care coordination and management for patients over time, ensuring continuity of care, optimal health outcomes, and appropriate utilization of services. This role supports patients across the continuum of care following initial assessments through regular monitoring, plan adjustments, and collaboration with multidisciplinary teams.


Key Responsibilities:

• Manage a caseload of patients longitudinally, tracking health status, progress, and care needs.


• Update and adjust individualized care plans based on patient condition, clinical goals, and evolving needs.


• Coordinate with physicians, specialists, community resources, and other care providers to ensure comprehensive care delivery.


• Conduct regular patient outreach via phone or telehealth to monitor health, provide education, and reinforce care plans.


• Identify barriers to ca...