Job Description
Join a mission-driven healthcare organization focused on improving patient outcomes and delivering coordinated, community-based care. This role plays a critical part in ensuring continuity of care and optimizing patient health through comprehensive care management.
Responsibilities:
- Develop, implement, and monitor individualized care plans in collaboration with patients, families, and healthcare providers
- Review and evaluate patient assessments and clinical data to identify risks and care needs
- Partner with primary care physicians to discuss and address patient care concerns
- Coordinate services across the continuum of care, including discharge planning
- Conduct routine patient monitoring and follow-ups to ensure quality care delivery
- Identify clinical issues requiring intervention to prevent hospitalizations or ED visits
- Facilitate utilization review processes and colla...