Care Management Specialist

Identify the targeted risk population per PCP referral, risk stratification, and patient lists Handle case management assignments, review case progress in accordance to center guidelines Coordinate patient care through ongoing collaboration with PCP, patient/family, community, and other members of the health care team. Foster a team approach and include patient/family as active members of the team Create and update personalized health care plans for patients by assessing patient’s wellness, needs, preferences and ability to utilize the care plans Communicate and establish effective working relations with care team Advocate and work with patient and patients’ family to achieve treatment goals Educate patients and caregivers about their health care plan and health care options Conduct regular follow-ups with patient to evaluate progress, ensure continuity of care and promote optimal health outcomes Summarize report relevant to care management activity Maintain care management documentation in electronic health records Establish linkage to external social services programs, specialist services and payer’s care management services Participate in clinical service team meeting/activities Update knowledge base relevant to service population Perform other duties as assigned