+ 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 heal...