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 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 healthcareproviders,familiesand stakeholders to coordinatecareand services.
• Develop andimplement 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.
• Createsand 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.
• Identifiesand addressesbarriersofcare,thenescalating issues as needed.
• Stay up to date on regulation requirements, bestpractices 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