Case Manager

Company:
Soni Family Practice/The Doctors Center

Job title:

Case Manager

Division/Department:
Health Services

Reports to:

Director of Valued Based-Care/ VP health Services

Job Summary:

The case manager is responsible for overseeing complex patient cases,providing expert care coordination and driving quality outcomes.

This role assesses patient needs,develops and implementscare plans,and collaborates with healthcare teams to ensure seamless transition andoptimalcarewith a focus on disease management.

• Conduct comprehensive patient assessments to identify needs and develop individualized care plans.
• Collaborate with healthcare providers,families and stakeholders to coordinate careand services.
• Develop and implement Disease Manageemntplans for patients with chronic condition(e.g.:diabetes,hypertension,asthma/COPD heart failure, CKD).
• Activelyparticipatesin censusmanagement,identifyingpatientswith highutilizationpatterns.
• Identifiesroot causes of admissions anddevelopstargeted interventions to mitigate risk.
• Creates and executesplans of care to address,andidentifiesneeds,toprevent future admissions.
• Analysis ofdata and metrics to inform care decisions and drive outcomes.
• Leadsorparticipatesin care planning meetings and case conferences.
• Provideseducation and support to patients and families on care plans andself-managementstrategiesanddiseasemanagement progress.
• Identifies and addressesbarriersofcare,thenescalating issues as needed.
• Stay up to date on regulation requirements, best practices and industry trends in disease management.
• Mentors or supervises junior care coordinators.
• Participates in quality improvement initiatives and special projects.

• Must be detail-oriented, possess the ability to multi-task/problem solve, and be open to cross-functional training.
• Exercise proper phone etiquette and navigate computer software systems proficiently.
• Be team-oriented and work well with patients, colleagues, physicians, and other personnel in a professional and courteous manner.
• Have exceptional organizational skills with the ability to prioritize and complete tasksin a timely manner.
• Knowledge of medical terminology, CPT, HCPCS, and ICD coding preferred.
• Bilingual is a plus