Case Management Coordinator

Job Summary

The Case Management Coordinator manages the transition of care for members post-discharge and those with chronic conditions, coordinating follow-up care, creating personalized care plans, and educating patients and caregivers, to prevent hospital readmissions, reduce over-utilization, and improve overall health outcomes.

Essential Job Functions

• Conduct timely post-discharge outreach (within 24-72 hours), reviewing discharge summaries, medication lists, and follow-up recommendations, to assess member needs, confirm understanding of medical instructions, and identify immediate gaps in care.
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  • Collaborate with primary care providers, specialists, home health agencies, and community resources to ensure seamless continuity of care across the continuum.
• Develop and implement individualized care plans based on assigned program categories, identifying early signs of complications or risk factors, to manage chronic conditions effectively and escalate clinical issues appropriately.
• Educate members and caregivers using motivational interviewing techniques, providing guidance on red-flag symptoms and self-management strategies, to empower patients and reduce patterns of over-utilization (e.g., frequent ED visits).
• Document all interactions, assessments, and clinical interventions in the care management platform accurately and timely, to maintain compliance with organizational policies, advocate for member needs, and ensure alignment with clinical guidelines.