Case managers are responsible for developing care plans in partnership with patients, monitoring ongoing symptoms, building continuity of care, reviewing patients claims data, laboratory reports, and prescriptions, engaging with patients to manage their own health, and working with patients and providers to set treat-to-target goals.
• Develops patient care plans based upon the assessment of the patients’ care needs and provides ongoing monitoring of assigned patient case load through the duration of the program. Maintains client records by reviewing case notes, logging events and progress.
• Monitors cases by verifying patients’ attendance to scheduled appointments; observing and evaluating treatments and responses; advocating for needed services and entitlements; obtaining additional resources; intervening in crises; providing personal support.
• Determines patients’ requirements by completing intake assessments; determining the need for therapeutic medical, psycho-social, and psychiatric evaluations; reviewing therapist evaluations, treatment objectives, and plans.
• Provides ongoing follow-up support and education to patients and caregivers, either in-person or telephonically, until transitioning the patient back to their primary care provider or ambulatory care manager for long-term support. Ensures that assigned patients who are discharged from any inpatient institutions are followed up by their primary care providers within 7 days. Communicates the patient plan of care with the physician, patient and care team members. Remains aware of patient needs and changes in patient¿s condition.
• Performs disease management for members with specific chronic diseases. Performs initial assessment which is used to determine the member¿s level of knowledge about their disease, as well as the need for education, coaching and support to ensure compliance with a treatment plan based on nationally recognized standards of care for their chronic illness(s). Works with patients to create disease specific disease management plans to address their specific objectives and goals established during the initial assessment.
• Responsible for timely contact of members enrolled in the Disease Management program. Maintains appropriate caseload, follows Disease Management process to include appropriate documentation and follow-up.