Clinical Care Manager

Manage a panel of high-risk patients with multiple chronic conditions, providing comprehensive, patient-centered care management.

Care Coordination

Coordinate care across the healthcare continuum, partnering with primary care providers, specialists, hospitals, home care, and community organizations.

Education and Coaching

Empower patients through education and coaching, using motivational interviewing and evidence-based strategies to improve self-management and achieve health goals.

Develop and Monitor Individualized Care Plans

• Conduct assessments
• Identify barriers to care
• Support patients through ongoing outreach and follow-up

Documentation and Compliance

• Document care accurately
• Maintain compliance with CMS Chronic Care Management (CCM) requirements, quality standards, and organizational policies

Interdisciplinary Collaboration

Collaborate with an interdisciplinary team to improve patient outcomes, reduce avoidable utilization, and advance population health initiatives.

Continuous Improvement

• Contribute to continuous improvement through quality initiatives
• Participate in professional development
• Achieve evidence-based care management practices