Care Manager

Assess patient care management needs via intake assessments and maintain established caseload sizes while meeting monthly productivity requirements. Conduct hospital discharge calls within 24 hours to confirm outpatient appointments, schedule necessary follow-ups, and coordinate transitions from inpatient to outpatient care. Perform pre-visit planning for high-risk patients, advocate for barriers to care including language and insurance issues, and assist with accessing medical, behavioral health, and community services. Provide case management services in the office and via home visits to promote efficient care, utilizing Motivational Interviewing to assist patients in achieving behavior change goals and implementing care plan objectives. Maintain electronic records, compile statistical data, and assist patients and families with benefits, entitlements, housing, and transportation needs.