• The ConcertoCare Case Manager coordinates all aspects of a patient’s care (medical, behavioral, functional, and social) and serves as a patient advocate across the continuum of care in partnership with the patient’s providers and extended care team. • Conduct initial intake calls as well as scheduled and urgent patient outreach based on individual patient’s needs and risk levels to review and update the care plan, monitor progress, ensure needs are met, and identify new areas of concern. • Provide ongoing care coordination for an assigned panel of complex patients. • Conduct needs assessments and develop plans of care in partnership with the rest of the patient’s care team. • Ensure care is coordinated, patient-centered, and aligned with the needs and wishes of the patient. • Support patients during care transitions, including outreach and assessment during and post hospitalization to ensure discharge needs are addressed, to facilitate provider follow-up, and to perform medication reconciliation. • Identify and implement interventions and collaborate closely with ConcertoCare’s multidisciplinary team (providers, Director of Clinical Care, social work, behavioral health, and clinical pharmacy), external providers, and social service organizations to: (1) address gaps in care, (2) mitigate the risk of inpatient admissions, readmissions, emergency room visits and movement to an institutional setting, (3) and keep patients safely living in their desired and appropriate home environment. • Identify and verify appropriate utilization of resources across the continuum of care. • Actively participate in interdisciplinary care team huddles, and other clinical meetings. • Participate in quality improvement and evaluation processes. • Adhere to compliance policies, procedures, and standards of conduct including all applicable laws and regulations. • Serve as a mentor for new hires and existing case management team members. • Other duties as assigned.