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 implements care plans, and collaborates with healthcare teams to ensure seamless transition and optimal care with a focus on disease management. Essential Duties and Responsibilities Conduct comprehensive patient assessments to identify needs and develop individualized care plans. Collaborate with healthcare providers, families and stakeholders to coordinate care and services. Develop and implement Disease Management plans for patients with chronic condition(e.g.:diabetes,hypertension,asthma/COPD heart failure, CKD). Actively participates in census management, identifying patients with high utilization patterns. Identifies root causes of admissions and develops targeted interventions to mitigate risk. Creates and executes plans of care to address, and identifies needs, to prevent future admissions. Analysis of data and metrics to inform care decisions and drive outcomes. Leads or participates in care planning meetings and case conferences. Provides education and support to patients and families on care plans and self-management strategies and disease management progress. Identifies and addresses barriers of care, 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. Qualifications 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 tasks in a timely manner. Knowledge of medical terminology, CPT, HCPCS, and ICD coding preferred. Bilingual is a plus #J-18808-Ljbffr
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