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+ 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 include 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