Location & Practice Overview

This Nurse Care Manager role supports a new care management program operated through the Health Federation of Philadelphia. The work centers on collaboration with six community health centers and a Medicaid Managed Care Organization serving patients across Philadelphia and surrounding counties.

Practice Type Network of community health centers
Care Model Team-based care management with social work and community health workers
Primary Setting Primarily telephonic with limited in-person contact
Geographic Scope Philadelphia and surrounding counties
Partner Entities Six community health centers and one Medicaid MCO

Responsibilities

  • Conduct initial and periodic holistic assessments of high-risk patients and prioritize follow-up based on clinical intensity and need.
  • Develop and implement mutually agreed care management plans with the patient, family, and interdisciplinary team.
  • Perform medication reconciliation after hospital discharge and support patient-directed strategies for ongoing adherence.
  • Complete outreach and follow-up for patients with recent inpatient or emergency department contact who are at elevated risk of readmission; conduct hospital or home visits when clinically indicated.
  • Coordinate referrals and serve as liaison among health center providers, inpatient facilities, skilled nursing facilities, and the Medicaid MCO to maintain continuity across the care continuum.

Documentation must remain accurate and timely. Continuous communication with health center care teams is required to prevent duplication of effort and keep all members informed of patient status.

Qualifications & Requirements

Candidates must hold an active Pennsylvania RN license. Prior care management experience focused on vulnerable populations with chronic physical or mental health conditions is required.

Licensure
Current Registered Nurse license in Pennsylvania
Education
RN required; BSN or master’s-level training preferred
Experience
Minimum 2 years as a nurse care manager working with high-risk or chronically ill populations
Technical Skills
Proficiency with electronic health records, payer portals, Microsoft Office, and Google applications
Preferred Background
Community health center or Medicaid program experience; Spanish or other language ability is an advantage

Compensation & Benefits

Annual salary ranges from $70,000 to $80,000 based on experience and qualifications. A comprehensive benefits package is available consistent with Health Federation of Philadelphia policy.

  • Medical coverage that includes vision benefits
  • Dental insurance and flexible spending accounts
  • Life, AD&D, long-term care, short-term, and long-term disability insurance
  • 403(b) retirement plan with company contribution
  • Paid time off covering vacation, sick, personal days, and holidays plus an Employee Assistance Program

Schedule & Work Environment

Employment Status Full-time, exempt
Primary Work Mode Telephonic with limited face-to-face patient contact
Office Base Standard office setting with regularly scheduled meetings and trainings at participating health centers
Travel Expectation Ability to travel within Philadelphia and surrounding counties by public transit or personal vehicle; occasional hospital or home visits
Physical Requirements Extended computer work and ability to lift up to 15 pounds

Patient Population & Clinical Setting

The program targets low-income patients enrolled with a Medicaid Managed Care Organization and attributed to one of six partner community health centers. Focus is on individuals at high risk of poor outcomes who have chronic physical or mental health conditions and who may not be engaged in regular primary care or who have recent hospital or emergency department contact.

Primary Population Low-income Medicaid-enrolled adults with complex chronic needs
Clinical Focus Chronic physical and mental health conditions plus social determinants of health
Engagement Priority Patients not regularly accessing assigned primary care and those with recent acute care utilization
Care Goals Improved health status, reduced hospitalizations, and closure of quality metric care gaps

About Health Federation of Philadelphia

The Health Federation of Philadelphia has operated since 1983 as a network supporting community health centers in Southeastern Pennsylvania. It provides a forum for the region’s federally qualified health centers and the Philadelphia Department of Public Health to collaborate on expanding access to high-quality care for underserved and vulnerable populations.

Founded 1983
Organizational Role Network of community health centers in Southeastern Pennsylvania
Mission Focus Improving access to and quality of health care for underserved individuals and families
Key Partners Federally qualified health centers and the Philadelphia Department of Public Health

Frequently Asked Questions

Is this primarily a telehealth or in-person role?
The position is described as primarily telephonic with limited face-to-face patient contact. Occasional hospital or home visits may be required when clinically necessary.
Who else is on the Care Management Team?
The team consists of four members: the Nurse Care Manager, a Team Manager who is a Social Worker, and two Community Health Workers. The Nurse Care Manager serves as the primary clinical professional.
Will I need my own vehicle for travel?
Travel within Philadelphia and surrounding counties is required. Candidates must be able to travel effectively either by public transportation or in a personal vehicle. Limited travel beyond the surrounding counties may also occur.
How are high-risk patients identified for this program?
Patients are those attributed to one of the six partner community health centers, enrolled with the participating Medicaid MCO, and designated as high risk or having experienced care transitions. The team prioritizes individuals not receiving regular primary care and those with recent hospital or emergency department contact.
Is Spanish language ability required?
It is not required. Ability to work with patients in a language other than English, especially Spanish, is listed as a preferred qualification.
How should applications be submitted?
All applicants must apply through the official link provided by the Health Federation of Philadelphia and upload both a resume and cover letter. Applications submitted outside that process may not be considered.

Nurse Care Manager in Philadelphia, PA

This Nurse Care Manager position anchors a newly launched care management program designed to reduce health inequities among Medicaid-enrolled patients attributed to community health centers in Philadelphia. The role emphasizes telephonic outreach, holistic assessment, medication reconciliation after acute care episodes, and cross-continuum coordination with primary care teams, hospitals, skilled nursing facilities, and a Medicaid Managed Care Organization. Working within a four-person team that includes a social worker and community health workers, the nurse focuses on engaging high-risk individuals who are disconnected from regular primary care or recently discharged from inpatient or emergency settings. The position requires Pennsylvania RN licensure, at least two years of care management experience with chronically ill and vulnerable populations, and the ability to travel locally as needed for limited in-person contacts.

Apply for This Position

Submit your application for Nurse Care Manager at Health Federation of Philadelphia.

Continue to Official Application Direct submission to Health Federation of Philadelphia