What are the responsibilities and job description for the Care Management Specialist - Internal Medicine position at cbwchc?
- Identify the targeted risk population per PCP referral, risk stratification, and patient lists
- Handle case management assignments, review case progress in accordance to center guidelines
- Coordinate patient care through ongoing collaboration with PCP, patient/family, community, and other members of the health care team. Foster a team approach and includes patient/family as active members of the team
- Create and update personalized health care plans for patients by assessing patient’s wellness, needs, preferences and ability to utilize the care plans
- Communicate and establish effective working relations with care team
- Advocate and work with patient and patients’ family to achieve treatment goals
- Educate patients and caregivers about their health care plan and health care options
- Conduct regular follow-ups with patient to evaluate progress, ensure continuity of care and promote optimal health outcomes
- Summarize report relevant to care management activity
- Maintain care management documentation in electronic health records
- Establish linkage to external social services programs, specialist services and payer’s care management services
- Participate in clinical service team meeting/activities
- Update knowledge base relevant to service population
- Perform other duties as assigned
HIV Specialist-Internal Medicine Provider
Betances Health Center -
New York, NY