United Health Centers

Manager

• Coordinate care for high-risk and chronic disease patients to improve health outcomes
• Provide patient education, care coordination, chronic disease management support, transition-of-care services, and population health interventions
• Assist in developing self-management skills and achieving individualized health goals
• Monitor patient progress and identify barriers to treatment adherence and disease management
• Coordinate care between primary care providers, specialists, hospitals, skilled nursing facilities, home health agencies, and community resources
• Conduct outreach and follow-up for patients following emergency department visits, hospitalizations, and other care transitions
• Document patient encounters accurately and timely within the electronic health record
• Promote timely post-discharge follow-up to reduce avoidable readmissions

Case Manager, RN