It's rewarding to be on a team of people that truly believe in making an impact! We are committed to building the best primary care environment for patients and are seeking healthcare enthusiasts to join us. Job Summary Perform care management for patients with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize patient health care across the care continuum. Duties & Responsibilities Essential Duties & Responsibilities Structural recording of patient’s health information and keeping care plan in EMR Managing transition of care services post hospital discharge, ER, SNF, include PCP appointment, Medication Reconciliation Post Hospital Discharge (MRP) completion , and specialist follow up Assist with identifying high risk population (i.e., high utilizers, multiple co-morbidities, polypharmacy, non-compliant, oxygen dependent, bed and wheelchair bound etc...) Conduct assessments to identify individual needs and a specific care management plan to address objectives and goals during assessment(s) for patients enrolled in Care/Disease Management Provide patients with education based on medical condition and co-morbidities Ensures patient access to appropriate resources (i.e. community resources, social services, behavioral etc...) Participate in Interdisciplinary Care Team (ICT) meetings with patient’s provider to communicate patients progress with his/her treatment plan, discuss complex issues or barriers to care Assist in utilization for high-risk population. Accurately updating and maintain team Share-point and Case/Disease Management cases Implement activities to promote cost savings such as: Potentially prevent admissions by coordinating outpatient care Reduce readmissions (Target 10%) Improve Generic Dispensing Rates Improve staff competence by providing educational resources; balancing work requirements with learning opportunities; evaluation the application of learning to changes in treatment results Supervisory Responsibilities No supervisory responsibilities Education & Experience High school education or higher At least two years of related work experience are preferred. Licensed: Medical Assistant, LPN, Health Coach, or CNA. Education Requirements Required/Preferred Education Level Discipline Required High School Knowledge, Skills & Proficiencies Strong written and verbal communication skills Bi-lingual preferred Time-management and organizational skills Critical thinking skill Skills with Windows-based operating systems and EHR Skills in operating phones, computers, software and other IT systems. Ability to communicate with employees, patients and other individuals in a professional and courteous manner. Attention to detail, ensure accuracy of reports and data. Job Requirements Physical Requirements This position works in one of our medical clinics. The employee is required interact with patients face to face and/or telephonically. Must be able to stand, sit, walk and occasionally climb. The incumbent must be able to work extended and flexible hours and weekends as needed. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This position works under usual office conditions. The employee is required to work at a personal computer as well as be on the phone for extended periods of time. Must be able to stand, sit, walk and occasionally climb. The incumbent must be able to work extended and flexible hours and weekends as needed. Physical demands include ability to lift up to 50 lbs. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Work Conditions Must be able to perform essential functions such as typing, standing, sitting, stooping, and occasionally climbing Travel Requirements Travel Required Amount of Expected Travel Details Yes 0-25% Work will involve some driving/traveling to assigned clinics. Tools & Equipment Used Computer and peripherals, standard and customized software applications and tools, and usual office equipment. Disclaimer The duties and responsibilities described above are designed to indicate the general nature and level of work performed by associates within this classification. It is not designed to contain, or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of associates assigned to this job. This is not an all-inclusive job description; therefore, management has the right to assign or reassign schedules, duties, and responsibilities to this job at any time. Cano Health is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law. Join our team that is making a difference! Please see Cano Health’s Notice of E-Verify Participation and the Right to Work post here Together, we have the opportunity to serve and grow with purpose. Find your team and begin your journey of transforming healthcare! Let us know you’re interested in a future opportunity by clicking ‘Get Started’ below. For more updates and engagement, create an account by clicking ‘Sign In’ above.