ACO Case Manager: Care Coordination & Transitions

CareConnectMD, Inc.; Quincy (MA); Hybrid; USD 75,000 - 90,000; Full time

Job summary

CareConnectMD, Inc. in Quincy, MA, is seeking an on-site Case Manager to support and coordinate care for patients enrolled in the ACO program.

You will focus on utilization management, reduce avoidable hospitalizations and ER visits, and improve transitions of care in collaboration with PCPs, nursing facilities, hospitals and care teams. The role requires excellent communication, critical thinking and the ability to build strong relationships with patients, families and facilities.

Qualifications

• At least 2 years of experience in healthcare case management.
• Experience in working in long-term care settings preferred.
• Experience with frail, medically complex geriatric patients.
• Knowledge of Medicare guidelines, including skilled nursing facility utilization, medical necessity, discharge planning, and care coordination.
• Experience working with electronic medical records, care management platforms and Microsoft Office.

Responsibilities

• Coordinate care for an assigned population of ACO patients using a patient-centered approach.
• Serve as an extension of the PCP, coordinating care and communicating among patients, families, facilities, and the care team.
• Develop innovative approaches to patient care to overcome barriers and improve engagement.
• Maintain timely, complete documentation in compliance with policies.
• Collaborate with facility staff to ensure care aligns with medical necessity.
• Communicate with family members to optimize outcomes.
• Act as liaison to facilities to ensure continuity of services per Plan of Care.

Skills

Excellent communication

Interpersonal skills

Strong organizational skills

Time management

Independent worker

Education

Licensed Nurse (LVN/RN)

Tools

EMR systems

Care management platforms

Microsoft Office

Job description

CareConnectMD, Inc. in Quincy, MA, is seeking an on-site Case Manager to support and coordinate care for patients enrolled in the ACO program.

You will focus on utilization management, reduce avoidable hospitalizations and ER visits, and improve transitions of care in collaboration with PCPs, nursing facilities, hospitals and care teams. The role requires excellent communication, critical thinking and the ability to build strong relationships with patients, families and facilities.