Hybrid Care Management Coordinator - Brandon bei Humanitary Medical Center

The Care Manager Team at Humanitary Medical Center, plays a key role in delivering patient-centered, coordinated care within the primary care setting. This position is responsible for managing patients with chronic conditions, high-risk medical needs, and those transitioning between care settings. The Care Manager works closely with providers, staff, patients, and community partners to improve health outcomes and support the overall well-being of patients.

Key Responsibilities:

Care Coordination:

• Serve as the primary point of contact for care management activities.
• Coordinate Hospital/ER follow up appointments with PCP in timely manner.
• Coordinate and monitor periodic PCP appointments for patients with Chronic conditions and High-Risk population.
• Facilitate communication between the care team and patients/caregivers.

Chronic Disease & High-Risk Patient Management:

• Identify and proactively manage patients with chronic illnesses (e.g., diabetes, hypertension, CHF, COPD).
• Carry out follow-up phone calls to patients to timely detect their health needs according to the guidelines and objectives of the established health programs.
• Develop and implement individualized care plans in collaboration with providers.
• Provide education and support to improve adherence to treatment plans.

Transitions of Care:

• Contact patients post-discharge from hospital, ED, or rehab to review medications, appointments, and instructions.
• Carry out post hospitalization follow up calls to monitor the patient’s compliance with provider instructions, detect any health needs and monitor the patient progress,
• Address barriers to follow-up care and help prevent readmissions.

Documentation & Reporting:

• Accurately document care management activities in the electronic health record (EHR).
• Track and report outcomes, quality metrics, and performance measures.
• Participate in interdisciplinary team meetings and case reviews.
• Collaborate with Medical records department to obtain hospital records in timely manner

Qualifications:

Required:

• Medical Assistant (MA) with current state licensure.
• 2+ years of clinical experience in a primary care, care management, or related setting.
• Strong communication, organizational, and critical thinking skills.
• Proficiency in using electronic health records (EHRs) and Microsoft Office.

Preferred:

• Experience in case management or working with high-risk patient populations.
• Knowledge of value-based care programs (ACO, PCMH, CCM, etc.).

Work Schedule and Environment

• Full-time, Monday–Friday, 8:00 am to 5:00 pm
• Primarily office-based within a clinical setting.
• Collaboration with a multidisciplinary care team.
• Work Location: 731 S. Parsons Ave. Brandon FL 33511