Job Description
Key Responsibilities:
1. Care Coordination & Management
- Caseload Management: Manage an assigned caseload of patients (e.g., Medicare/Medicaid beneficiaries), ensuring regular contact frequencies are met according to acuity levels.
- Resource Linkage: Act as the liaison between the patient, primary care providers (PCPs), specialists, and community resources to close gaps in care.
- Barriers to Care: Identify Social Determinants of Health (SDOH) such as transportation or financial issues and coordinate with social workers or community liaisons to resolve them.
- Documentation: Maintain accurate, comprehensive, and compliant documentation of all patient interactions in the Electronic Health Record (EHR) in real-time.
2. Transitions of Care (TCM)
- Admission/Discharge Tracking: Monitor patient census to identify hospital admissions and discharges daily.
- Post-Discharge Follow-up: Conduct telephonic outreach within 2...