Director of Care Mgmt.

Identify high-risk patients through case finding activities and develop person-centered care plans based on patient goals and disease states. Coordinate transitional care following critical events like hospital admissions or ED use, while conducting longitudinal outreach to build trusting relationships and engage in self-management support. Implement approved care plans through practice, community, and telephonic support, utilizing motivational interviewing to assess barriers and provide culturally competent interventions. Advocate for timely service delivery, optimize benefits, and collaborate with the care team to address gaps in care and facilitate effective transitions. Complete documentation for billing and evaluate progress toward goals to determine discharge from management.