Website Arizona Community Physicians

Job Summary

Works under the direction of the ACO Medical Director and Care Coordinator Manager in the area of Care Management and Population Health. A prime area of focus will be case management of higher risk patients. Other areas of focus may include transitional care management, population health management, quality improvement, and provider and staff education.

Minimum Qualifications

Education:  Completion of an accredited MSW program.

Work Experience:  Minimum of two years of experience in case management, preferably in a medical setting

Preferred Experience/Qualifications:  Prior experience in case management, population health management, utilization management and quality programs. CCM credential is desirable.

Other Qualifications:  Excellent written and verbal communication skills.  Proficient with MS Word, Excel and Outlook.  Valid Arizona driver’s license and reliable transportation.


Clinical: Provide case management to a panel of high risk patients (typically 75 to 100 patients) and work with the ACP Medical Director to improve clinical outcomes and help reduce total medical costs. Assist in ACO-directed quality improvement efforts.

Care Coordination – Interact daily with clinical offices affiliated with Abacus Health to provide care coordination for patients needing short-term and/or chronic care coordination

Case Management – Develop and maintain a panel of high risk patients with the purpose of helping
them be more effective at managing their own care, understand their medical conditions and medications, navigate the healthcare system and utilize resources appropriately. Provide education and emotional support to these patients and develop trusting relationships with them. Meet their paneled
patients face-to-face at least once in their physician’s office or other healthcare facility or the patient’s home. Create a patient centered-care plan with each patient and consistently log all interactions with each patient. Complement and support the chronic care management provided to these patients by their primary care provider. Communicate significant clinical information regarding these patients to other members of the healthcare team and especially to the patient’s PCP.

Short term Care Management – One -time or limited outreach assistance with care coordination
Assist other ACO staff with closing of clinical gaps in care.

Attend case conferences in regards to patient collaboration

Act as a liaison between community resources helpful to patients (e.g. volunteer agencies, assistance programs) and educate assigned ACP staff about community resources that can help them in office management of high risk patients. Use advocacy, communication and resource management, while promoting quality and cost-effective interventions and outcomes. Facilitate the achievement of patient wellness and autonomy through advocacy, assessment, planning, communication, education, resource management, and service facilitation. Maintain appropriate documentation to track quality improvement and cost reduction activity







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