Coordinates and participates in activities related to Care Management services to family members and caregivers.
- Utilizes patient-centered motivational interviewing techniques to build rapport and help patients improve their health.
- Supports the primary care team by providing panel management to decrease the number of patients lost to care, non-compliant in follow up care or disconnected from primary care. Participates in the development, maintenance, and adjustment of individualized care plans for high-risk patients that address both medical and social barriers to accessing care.
- Acts as a professional liaison between hospitals, primary care providers, specialists, and community resources on behalf of patients to ensure patient-centered care coordination.
- Identifies and tracks special populations, including high-risk patients and other populations due for preventive or chronic care services.
- Identifies and tracks patients discharged from the inpatient service or the emergency department.
- Uses team-based communication strategies to close the loop on referrals, hospital follow-ups and any outstanding items identified in the patient's care plan. Performs outreach activities in primary care sites, homes, hospitals, and neighborhoods.
- High School Diploma or equivalent required.
- 1-3 years of relevant experience, required.