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Dinesh Khanna MD LLC ES Lady Lake, FL

  • Posted: over a month ago
  • Full-Time
Job Description

 The role of the ACO Case
Manager is to support the Care Team
(Provider, nurse, medical assistant, other health providers and CCC’s/PCC’s) in
optimizing health and quality of life for individuals with multiple chronic
conditions by: 

Following up on the care for ACO patients, so as to
offer management of care during intervals between face to face interactions
with the healthcare delivery system in Hospitals and Skilled Nursing Facilities
in order to facilitate patients being cared for at the lowest level of care
possible is a critical component of Care Coordination. 

of services for all patients who are part of the assigned group, which

  • All hospitalized patients,
    ER diversion and Skilled Nursing Facilities patients 
  • ACO patients with multiple
    (two or more) chronic conditions expected to last at least 12 months, or
    until the death of the patient; 
  • Chronic conditions which
    place the patient at significant risk of death, acute
    exacerbation/decompensation, or functional decline; 

Will provide
advocacy, information and referral services to patients and families to address
their medical and psychosocial needs in accordance with the physician’s written
plan of care. 


  • Knowledge in appropriate
    assessment and assistance techniques. 
  • Knowledge in health
    information management by appropriately charting patient data. 
  • Knowledge in the utilization
    of tact. 
  • Knowledge and demonstrated
    proficiency in performing clinical skills. 
  • Ability to communicate
    clearly, with emphasis on excellent telephone skills. 
  • Ability to exercise
    professionalism in dealing with all levels of personnel, patients, and
    patients families. 



  • Review of the patient care
    plans, initiation of telephone communication to the patients, discussion
    of the care plan with the patient, and, clarification of expectations
    related to the care plan. 
  • Creating education programs
    for both staff and patients on High Risk Diagnosis 
  • Education and collaboration with Call Centers and
    Office staff to triage clients  
  • Assist with implementing
    telemedicine for ACO clients 
  • Handle non-appointment
    related calls from assigned patients that involve care coordination,
    follow-up, etc. 
  • Assist patients with
    community resources as needed. 
  • Keep physician informed of
    patient condition changes and potential changes in the plan of care. 
  • Provide an effective
    communication link between assigned patients/caregivers and medical staff,
    including relaying messages from providers, gathering information from
    patients for providers, etc. 
  • Support patients and
    providers in the Case Management Program, with care
    compliance when such intervention requires resources, community
    referrals, etc 
  • Ensure that all panel patients
    are tracked for follow-up and reporting. 
  • Ensure that pertinent data
    and tracking information is entered into the PM and or EMR systems. 
  • Quarterly review information
    for assigned patients and verify and validate care delivered to
    proactively coordinate healthcare needs. 
  • Coordinate with the medical
    staff to ensure that referral care management services are provided
    to patients with complex medical and/or psychosocial problems. 
  • Work with the medical staff
    to develop, implement and carry out programs in chronic disease
    management for patients, with such problems as diabetes, asthma,
    congestive heart failure, hypertension, depression, and other
    disease/condition states based on chronic disease management model. 
  • Ensure that disease and quality
    data entry is up to date and use y reports to organize plan of care for
    complex patients. 

Education/Experience: Minimum of
two year’s clinical experience, preferably in a hospital or office practice
setting working with complex medical needs clients.  

Dinesh Khanna MD LLC ES


Lady Lake, FL
32159 USA



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