Millennium Physician Group
  • 02-Jan-2019 to 03-Mar-2020 (EST)
  • Fort Myers, FL, USA
  • Salary
  • Full Time


The ACO Acute Care Case Manager is responsible for the direct provision of services that assist patients with the achievement of their highest level of wellness.  S/he is focused on patient centered services that link patients and other family members with health care, psychosocial and other home and community based services to ensure timely, coordinated access to medically appropriate levels of health and support services and continuity of care.  S/he is responsible for assessment, care planning, coordination, advocacy, education, monitoring, and accurate, timely documentation in all program areas.  S/he demonstrates knowledge of growth and development and possesses the ability to assess, interact, communicate and care for age specific patient populations.



Essential Duties and Responsibilities include the following. Other duties may be assigned.

  • Primary patient focus in on ACO patients with acute needs who are not already enrolled in Case Management/Chronic Care Management and have been referred for case management by providers, hospital discharge planners, SNF Case Managers, TCM nurses, or other members of the patients' healthcare team.
  • Conducts comprehensive assessment that identify behavioral, clinical, psycho/social, and environmental concerns and needs of the patient.
  • Demonstrates ability to work with the patient, patient's physician and other members of the population health team to create a comprehensive and patient centered Care Plan that addresses the identified needs, removes the barriers for implementation of the plan and improve the health of the patient.
  • Coordinates/collaborates with the Social Worker to obtain assistance with local community and government resources for patients and their families and helps facilitate the patient's access to these resources.
  • Assesses the patient's knowledge of their clinical condition and provides education and self-management support based on the patient's unique learning style.
  • Maintains a caseload consistent with program guidelines
  • Provides verbal and written reports as requested.
Millennium Physician Group
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