KT
Case Management
Manage active care coordination cases, assignments, and member contacts
Case IDPatientPrimary DiagnosisCMOpenedRiskStatusNext Contact
CC-2025-0124
Dorothy Pearce
F / 78
 CHF, DM2, CKD Stage 3 Kim T. Jan 15 High Active Overdue
CC-2025-0123
Henry Wu
M / 71
 CHF — NYHA Class III Priya N. Mar 18 High Post-DC Today
CC-2025-0122
Maria Santos
F / 64
 DM2, HTN, Depression Priya N. Feb 22 Moderate Active Apr 2
CC-2025-0121
George Callahan
M / 82
 COPD, Frailty — SNF Marcus D. Mar 10 High Transition Apr 3
CC-2025-0120
Rosa Martinez
F / 58
 DM2 — Uncontrolled A1c Kim T. Jan 5 Moderate Stable Apr 8
CC-2025-0119
James Wilton
M / 66
 Atrial Fibrillation, HF Marcus D. Mar 1 High Active Overdue
CC-2025-0118
Sandra Park
F / 55
 HTN, Obesity, Pre-DM James O. Feb 14 Low Stable Apr 10
CC-2025-0117
Michael Chen
M / 73
 HTN — Uncontrolled, CKD Marcus D. Feb 28 High Alert Today
CC-2025-0116
Patricia Rhodes
F / 61
 DM2 — A1c improving Lisa R. Oct 12, 2024 Low Stable Apr 15
CC-2025-0115
Kevin Dunn
M / 69
 COPD — Moderate (GOLD 2) Lisa R. Mar 20 Moderate Active Apr 5
CC-2025-0114
Lucinda Park
F / 77
 CHF, DM2, Dual-Eligible Kim T. Nov 1, 2024 High Active Apr 4
CC-2025-0113
Harold Metz
M / 80
 Dementia, Falls Risk James O. Dec 3, 2024 High Active Apr 6
CC-2025-0112
Evelyn Torres
F / 67
 CKD Stage 4, Anemia Priya N. Jan 30 Moderate Active Apr 7
CC-2025-0111
Samuel Winters
M / 74
 Post-CABG recovery, DM2 Marcus D. Mar 5 Moderate Post-DC Apr 3
CC-2025-0110
Miriam Okafor
F / 59
 Schizophrenia, DM2 Kim T. Aug 10, 2024 Moderate Stable Apr 20
15 of 124 cases
Case Detail
High Risk
DP
Dorothy Pearce
CC-2025-0124 · F / 78
Primary DxCHF, DM2, CKD Stage 3
Care ManagerKim Torres
OpenedJan 15, 2025
Last ContactMar 15 (Overdue)
RAF Score2.14
Active Goals
✓ Reduce ER visits to 0 per quarter
● Achieve A1c < 8.0 by Jun 2025
● Daily weight monitoring — CHF mgmt
○ Improve medication adherence ≥ 80%
Recent Notes
Mar 15 — BP elevated at home visit, 168/98. Notified PCP Dr. Kim. Med adjustment ordered. F/U call scheduled for Mar 18 (missed).
AI Assistant

Click any row to view that case's detail panel on the right. Use filters to narrow the list by risk, CM, or status.

  • High — RAF ≥ 1.5, active clinical alert, or ≥ 2 ER visits in 90 days
  • Moderate — RAF 1.0–1.49 or ≥ 2 chronic conditions
  • Low — RAF < 1.0, stable, preventive focus

Log Contact records the date, time, type (phone, in-person, telehealth), and outcome of each member interaction. Contact frequency requirements: High = monthly, Moderate = quarterly, Low = semi-annual.

  • Overdue contacts are highlighted in red — these affect STAR Ratings
  • Cases auto-close after 90 days of stability at Low risk
  • RAF score shown in detail is the most recent CMS calculation