HealthKeeperz

Manager

• Conduct initial screenings and assessments of patients and families
• Identify social service needs and connect patients to appropriate community resources
• Evaluate eligibility, needs, and support systems
• Develop and update individualized care plans that promote patient health and safety
• Educate patients and families on care plans and available service options
• Initiate referrals and provide counseling to support family and caregiver well-being
• Coordinate care with interdisciplinary team members and external providers
• Perform regular follow-ups through home visits and phone check-ins
• Monitor and document care effectiveness and adjust plans as needed
• Provide monthly case management and attend interagency conferences as appropriate
• Maintain accurate, timely records per agency policy and CAP guidelines
• Document patient status, changes in condition, and care outcomes
• Complete discharge summaries and ensure all documentation is current in E-CAP
• Review aide documentation, recertifications, and billing codes for compliance

CAP Case Manager