The Care Manager collaborates with the care team within each practice and leverages Aledade’s interdisciplinary care team to provide telephone-based health coaching, quality improvement, and care coordination. The care manager works closely with Medicare patients to support them in becoming active in their health care.
Maintain and monitor your own patient census across multiple facilities. Coordinate the implementation of Chronic Care Management (CCM) services amongst chronically ill patients. Create individualized Care Plans, monitor labs, vitals, and medications, and coordinate with the care team.
The RN Care Manager collaboratively works with a team to review lab results, coordinate care, and educate patients. This role involves initiating care plans, assessing patient needs, and utilizing community resources, all while ensuring comprehensive care and adherence to treatment plans.