Description
Coordinate and manage care for individuals and families coping with chronic, acute, or terminal illnesses. Conduct assessments, develop and implement care plans, educate and support caregivers, and connect patients with resources and benefits. Facilitate care transitions, address barriers to access, and monitor outcomes through ongoing case management.
- • Collaborate with interdisciplinary teams to assess patient needs and plan care.
- • Screen for safety risks and suspected abuse or neglect and escalate per policy.
- • Connect patients and caregivers to community resources, benefits, and services.
- • Provide brief counseling, education, and coaching to support recovery and adjustment.
- • Facilitate support groups and deliver caregiver training.
- • Advocate for patients and resolve barriers during crises and care transitions.
- • Assess social determinants and environmental barriers through interviews and record review.
- • Develop, coordinate, and track individualized care plans based on assessments.
- • Update care plans as clinical status, goals, or coverage change.
- • Monitor outcomes against measurable goals and document progress in the EHR.
- • Coordinate and delegate tasks with support staff and service vendors to ensure timely services.
- • Contribute to quality improvement and care management program development.
- • Manage prior authorizations, benefits verification, and Medicare/Medicaid documentation.
- • Report utilization, length of stay, and readmission risks to support program metrics.
- • Coordinate health promotion, disease prevention, and substance-use risk reduction activities.
- • Lead discharge planning and arrange post-acute services, equipment, and follow-up.
- • Educate patients and families on advance care planning, hospice, and end-of-life options.
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Healthcare & Human Services
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Tasks & skills:
O*NET occupational data (work activities, skills, knowledge).
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Last reviewed: Jan 2026
