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* Works with the providers and clinic staff to identify patients at high risk telephonically primarily * Supports longitudinal care of the patient...
* Provides positive, supportive communication to patients, families, visitors, physicians and other personnel * Promotes the Agency image...
* Role embedded within the primary care clinic, working directly with patients, clinical and non-clinical teams * Participates in the identification...
* Demonstrates flexibility, enthusiasm and willingness to cooperate while working with others or in place of others, as necessary * Expresses...
* Assist in coordinating Medicaid/Medicare benefits with a multidisciplinary team approach * Build relationships and work with a variety of...
* Conducts medical home visits on established Bridges in Complex Care patients performing a hands-on exam at each visit * Conducts urgent / acute...
* Conducts medical home visits on established Bridges in Complex Care patients performing a hands-on exam at each visit * Conducts urgent / acute...
* Performs nursing assessments and develops, implements and evaluates plans of care in conjunction with the physician, patient and caregivers...
* Engage members face-to-face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral...
* Assist in coordinating Medicaid/Medicare benefits with a multidisciplinary team approach * Build relationships and work with a variety of...
* Demonstrates flexibility, enthusiasm and willingness to cooperate while working with others or in place of others, as necessary * Expresses...
* Performs nursing assessments and develops, implements and evaluates plans of care in conjunction with the physician, patient and caregivers...
* Works with the providers and clinic staff to identify patients at high risk telephonically primarily * Supports longitudinal care of the patient...
* Supports case management operations across the continuum of care (assessing, planning, implementing, coordinating, monitoring, and evaluating)...
* Demonstrates flexibility, enthusiasm and willingness to cooperate while working with others or in place of others, as necessary * Expresses...
* Demonstrates flexibility, enthusiasm and willingness to cooperate while working with others or in place of others, as necessary * Expresses...
* Population Management * * Analyzes data related to patient populations/conditions and develops a plan of action. Monitors progress over time...
* Applies motivational interviewing in identifying impact on member engagement and setting goals * Member education, medication reconciliation...
* Performs nursing assessments and develops, implements and evaluates plans of care in conjunction with the physician, patient and caregivers...
* Demonstrates flexibility, enthusiasm and willingness to cooperate while working with others or in place of others, as necessary * Expresses...
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