Care Manager

Care Plan Development: Develop and manage individualized, comprehensive care plans that align with organizational standards and program requirements. Support patients and families with honest advance care planning discussions and goal setting.

Behavioral Health Management: Execute on CoCM model and implement specific behavioral health interventions.

Clinical Partnership: Collaborate directly with MDs, CNPs, and PAs to provide real-time observations and update care strategies based on the patient’s evolving status.

Gaps-in-Care & Utilization Management: Proactively identify and close clinical and documentation gaps to support Value-Based Care (VBC) contracts, including ACO initiatives. Take accountability for meeting quality measures, optimizing performance benchmarks, and preventing unnecessary utilization to effectively manage the Total Cost of Care (TCOC).

Transition Management: Lead the coordination of hospital and rehab discharges to ensure seamless transitions, focusing on the prevention of 30-day readmissions.

Acute Care Facilitation: Manage on-site acute visit coordination, including the facilitation of telehealth services to ensure timely clinical interventions.

Resource Optimization: Navigate and deploy community and organizational resources to support the patient’s ability to remain in their home. Ensure patients are aligned with the most optimal Bluestone care management program available.