To support care continuity and patient safety, the full-time State Licensed Case Manager will systematically identify and close care gaps, collaborate with the clinical team, and manage patient follow-up appointments in a fully remote environment. Key responsibilities Complete biopsychosocial assessments to identify clinical, behavioral, and social needs Proactively identify and resolve gaps in the patient record and ensure timely access to specialty care Maintain accurate documentation in the EHR for all care management activities and facilitate coordination of community-based resources Required qualifications Licensed practical nurse (LPN), registered nurse (RN), licensed social worker (LSW/LICSW), or equivalent clinical training preferred Experience in primary care, care coordination, or case management strongly preferred Proficiency with athenahealth and familiarity with health information exchanges Knowledge of community behavioral health resources and comfort initiating related conversations with patients Strong organizational skills to manage a multi-patient registry across concurrent workflows