Esperanza Health Centers

Manager

• Coordinates screening and providing intervention of patients with identified complex chronic care needs
• Acts as a connector between patient needs and resources provided by the care management program
• Provides guidance and leadership through the care management program to Esperanza’s care teams
• Ensures patients receive the best possible care
• Identifies, tracks and manages care for the highest risk patients using electronic medical records
• Conducts initial care coordination screening eligibility and performs comprehensive risk assessments
• Manages a caseload of 62 patients
• Oversees development and implementation of integrated patient care plans
• Supports care managers and primary care teams
• Ongoing clinical assessment, monitoring and follow up for high-risk patients
• Performs medication review and reconciliation
• Oversees transitions of care process
• Participates in evaluation of care management programs including running data reports
• Collaborates in the selection, development and maintenance of patient education materials

Care Manager