Worcester, MA30+ days ago
The Care Manager, as an integral part of the primary care team, is responsible for ensuring that the primary care provider (PCP) and practice team maintains a central role in coordinating and managing the care of these vulnerable patients and that the patients receive optimal care including acute illness management, chronic disease management, and preventive care across multiple health settings and multiple physicians/providers. The highest risk patients are 1) transitioning to or from home and community-based health care facilities for acute care services (hospital or emergency department), rehabilitation services, skilled nursing services, or other community based services; 2) being seen in the office with co-morbidities, unmanaged disease severity, poor selfcare, polypharmacy, and high utilization rate.