Case Manager

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Full Time Professional

6 days ago Requisition

Salary Range: $75,000.00 To $90,000.00 Annually

Overview of Position

ACO Case Manager is responsible for supporting and coordinating the care of the patient participating in CareConnectMD's ACO program, with a strong focus on utilization management, reducing avoidable hospitalizations and ER visits, and improving transitions of care. The Case Manager serves as an extension of the patient's Primary Care Provider (PCP) and works closely with patients, families, nursing facilities, hospitals, providers, and the care team.

This role requires excellent communication, critical thinking, resourcefulness, and follow-through. The ACO Case Manager builds a strong relationship with patients, families, providers, and facility teams, serving as a reliable resource to help identify needs, resolve barriers, and coordinate appropriate care. Supporting the ACO's overall goals of improving quality and managing healthcare utilization.

This is an onsite position. Candidates must reside locally in the Woburn, Wakefield, Burlington, or Lexington, Massachusetts area and be able to work onsite.

Key Duties and Responsibilities

Patient & Care Management

• Manage and monitor an assigned population of ACO patients using CareConnectMD's patient-centered approach, recognizing each patient's individual needs, goals, preferences, and circumstances.
• Serve as an extension of the PCP, coordinating care, conduct regular outreach and communication among patients, families, facilities, and the care team.
• Develop innovative and creative approaches to patient care, identifying practical solutions to overcome barriers, improve engagement, and address complex patient needs.
• Maintains timely, complete, and accurate documentation in compliance with regulatory policies and procedures.
• Participates in multidisciplinary meetings, respecting and promoting patient choice and documents informed decision making.
• Collaborate with nursing facility staff to ensure that patient is receiving care that is appropriate and consistent with medical necessity.
• Collaborates and communicates with family members to optimize outcomes.
• Acts as an effective liaison to facilities (hospital, skilled nursing, assisted living, memory care, and mental health) to ensure continuity and congruity of services in accordance with the patient's Plan of Care.
• Specific to Care One, build a strong close working relationship with Bridge care providers, Care One facility operators and care team to ensure smooth.

Goals of Care & Advance Care Planning

• Ensures that patient's wishes are aligned and known to team. Participate in goals of care discussion.
• Verify that available code status and advance care planning documentation is complete and accessible to the care team, as appropriate.
• Support communication with patients, families, responsible parties, and providers regarding established goals of care.

Transitions of Care & Utilization Management

• Monitor patients when they are transferred to an acute setting (ED, hospital, LTAC), obtaining updates on patients for Clinical Team, facilitating transition of care and continuing to follow patient in the post-acute setting.
• Identify changes in condition, gather relevant information, and promptly escalation concerns to the appropriate clinician.
• Identify opportunities to support appropriate care in the most appropriate setting and reduce avoidable emergency department visits and hospitalizations.
• Assists facility for care coordination throughout the treatment episode at all levels of care as needed.
• Assist with provider-to-provider communication when needed.
• Communicates regularly with patient's primary care provider and other clinicians. Reviews and monitor patients' utilization of skilled Part A and Part B services in nursing facility to include documentation of medical necessity and continued stay review.
• Participate in root cause analysis of hospitalizations, ED visits, readmissions, or other utilization events when appropriate.

Care Coordination and Program Support

• Coordinates and communicates with the interdisciplinary team in the facility to effectively manage care plans and transition of care settings.
• Obtain and reconcile updated medication lists as part of care coordination activities.
• Support patient engagement and education regarding available ACO services.
• Facilitate…