Source Job

• Contact patient and complete a thorough assessment, including physical, psychosocial, emotional, spiritual, environmental, and financial needs.
• Develop treatment plan for standard and catastrophic cases in collaboration with the patient, caregivers or family, community resources and multi-disciplinary healthcare providers that include obtainable short- and long-term goals.
• Advocate for the patient by facilitating the delivery of quality patient care, and by assisting in reducing overall costs; provide patient/family with emotional support and guidance.

Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. They serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes and have a mission to empower people to lead healthier lives.

• Serves as a patient advocate and navigator, guiding patients and caregivers through the healthcare system.
• Completes emergency room and hospital follow-up calls, offering education on alternative access points to reduce avoidable ED visits.
• Facilitates medication education and adherence support, including alignment with standing orders, protocols, and chronic disease management goals.

Praxis Health is a family of medical groups providing high-quality healthcare throughout the state of Oregon. They are a company of small groups and clinics, of nimble micro-cultures that can quickly adapt to industry changes, as well as patient needs.

• Conduct targeted patient outreach to close care gaps and ensure timely care transitions.
• Deliver high-touch engagement for high-risk patients to prevent readmissions through follow-up.
• Collaborate with Practices to support interventions such as Transitional Care Management.

Aledade empowers independent primary care practices, helping them deliver better care and thrive in value-based care. Founded in 2014, they are the largest network of independent primary care in the country with a collaborative, inclusive, and remote-first culture.

• Educate patients and families on CKD management and modality choices.
• Coordinate services with interdisciplinary team (social worker, dietitian, pharmacist).
• Review medical records and update REACH EMR.

REACH Kidney Care, a division of Dialysis Clinic, Inc., is a kidney health management program designed to benefit patients along the continuum of kidney disease through health education, self-management, behavior change counseling, coordination of care with other providers, and patient navigation services.

• Deliver hands-on care navigation services to a diverse patient population.
• Partner directly with leadership to design and document care navigation workflows, SOPs, and standards of care.
• Contribute to hiring, mentoring, and performance of future team members.

Carewell is dedicated to providing trusted caregiving solutions and support for individuals and families. They extend commitment beyond products to person-centered navigation, care coordination, and advocacy services. Carewell has been recognized as one of the fastest-growing companies in the US.

• Collaborate with hospitals, rehabs, and SNFs to manage patient’s inpatient stay and desired discharge plan
• Communicate effectively with internal and external stakeholders in order to promote Bluestone’s mission and maintain patient health
• Help reduce unnecessary visits to the emergency departments as to acute settings with the goal of reducing utilization and unnecessary costs

Bluestone delivers great outcomes by bringing exceptional care to patients living with complex, chronic conditions and disabilities. Bluestone has been named to the Star Tribune's Top Workplace list for the 13th year in a row!

• Perform monthly CCM touchpoints for assigned patient panels.
• Evaluate changes in condition using licensed clinical judgment.
• Escalate urgent issues based on defined triage pathways.

Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach to kidney care. They are committed to improving patient outcomes and improving quality of life by delaying disease progression, shifting care to the home, and accelerating kidney transplants.

• Support proactive care coordination services for patients with complex chronic conditions.
• Conduct patient outreach, maintain care plans, and support documentation compliance.
• Coordinate communication between patients, providers, and healthcare partners.

Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach. They are committed to improving patient outcomes and improving quality of life.

• Engage with patients and healthcare providers via phone and virtually.
• Serve as a clinical resource for therapy adherence, addressing inquiries related to medication and side effects.
• Act as a liaison between healthcare professionals and patients, navigating therapy access challenges.

EVERSANA provides commercialization services to the life sciences industry with a global team of more than 7,000 employees. They serve over 650 clients, ranging from innovative biotech start-ups to established pharmaceutical companies, to bring therapies to market and support patients.

• Responsible for the coordination of services for members meeting established criteria, emphasizing education/self-management and promoting quality care and cost-effective outcomes.\n- Uses a collaborative process to assess Member needs, review options for services and resources, develop and implement a plan of care, coordinate resources, monitor progress, and evaluate Member status.\n- Addresses medical, psychosocial, clinical needs, and behavioral health needs including members with mental health and substance use disorder needs, providing counseling and referrals to community/local/state programs.

Capital Blue Cross is committed to providing excellent service to both its team and the community. Employees have consistently voted it as one of the “Best Places to Work in PA”, which indicates a positive and supportive company culture.

• Provide clinical oversight and guidance to CHWs and BHCMs, including escalation support for complex and high-risk patients
• Lead clinical case reviews, identifying gaps in care and ensuring care plans are clinically appropriate and aligned with health plan requirements
• Support care coordination across medical, behavioral health, and social needs, including collaboration with external providers and hospitals

Zócalo Health is a tech-enabled, community-oriented primary care organization serving people who have historically been underserved by the one-size-fits-all healthcare system. Founded in 2021, Zócalo Health is backed by leading healthcare and mission-aligned investors and is scaling rapidly across states and populations.

• Perform telephonic outreach to enroll and engage patients and establish connection as primary point of contact.
• Develop and implement care plans addressing the unique needs of patients.
• Connect members to appropriate resources such as housing assistance, transportation, food security, and community support programs.

Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach. They are committed to improving patient outcomes and quality of life by delaying disease progression and shifting care to the home.

• Use phone and video to provide follow-up care to post-hospital discharge patients.
• Coordinate patient care between hospitals, pharmacies, and community providers.
• Collaborate with the nursing team and meet individual performance targets.

Galileo is a team-based medical practice working to improve healthcare quality and affordability. They operate across 50 states, offering data-driven, multi-specialty care via phone and in-home visits; regional health plans, employers, and Fortune 500 organizations trust Galileo to improve population health.

• Conduct research to understand healthcare needs and identify ways to reach caregivers.
• Perform telephonic outreach to enroll children in care and ensure onboarding.
• Collaborate with healthcare professionals to support patient re-engagement.

Imagine Pediatrics is a tech-enabled, pediatrician-led medical group reimagining care for children with special health care needs. They deliver 24/7 virtual-first and in-home medical, behavioral, and social care, working alongside families, providers, and health plans.

• Coordinate case management activities related to medication optimization, adherence, and therapeutic appropriateness
• Collaborate with providers, PBMs, and pharmacy partners to support evidence-based medication use and access
• Conduct member outreach, education, and follow-up to support adherence and understanding

Point C is a national third-party administrator (TPA) delivering customized self-funded benefit programs with local market presence. They focus on cost containment strategies with innovative solutions. They are driven by a clear and impactful mission.

• Establish and maintain contact with assigned oncology members via phone, text, email, and video calls.
• Initiate nursing care plans, educating members on treatment regimens, symptom management, side effects, and disease-specific program benefits.
• Obtain and use clinical information to develop individualized member and clinician-centered care plans that complement oncologist guidance/plan of care.

Renalogic is dedicated to helping clients manage the human and financial costs of chronic kidney disease. They hire people who are humble, hungry, and smart, and their 96% client retention suggests they’re on the right path.

• Conduct assessments, establish care goals, and deliver telephonic coaching and education to support clients in managing chronic conditions.
• Perform first‑level Utilization Review for inpatient and outpatient services based on plan guidelines.
• Document all condition management activities, track client progress, and report outcomes, savings, and quality improvements.

Cottingham & Butler sells a promise to help their clients through life’s toughest moments and aim to hire, train, and grow the best professionals in the industry. Their culture is guided by the theme of “better every day” constantly pushing themselves to be better than yesterday.

• Handle inbound calls from patients and caregivers, providing compassionate and informed triage.
• Assist with finding appropriate providers, community resources, and care solutions and coordinate priority virtual appointments.
• Research information online and in Privia’s internal knowledge databases to make the most appropriate triage and care advice decisions.

Privia Health is a technology-driven, national physician enablement company that collaborates with medical groups, health plans, and health systems. They optimize physician practices, improve patient experiences, and reward doctors. Their platform is led by top industry talent and consists of scalable operations.

• Serve as a first-line resource for team support.
• Manage a caseload and deliver exemplary member-centric care as part of the interdisciplinary team.
• Deliver coaching and mentoring for quality improvement, best practices, and help drive performance.

Transcarent is the One Place for Health and Care, bringing medical, pharmacy, and point solutions together. More than 1,700 employers and health plans rely on them to provide information, guidance, and care, empowering health consumers with more choice and higher-quality care.

• Responsible for an appeals caseload.
• Responsible for the Care Coordination staff for case reviews and UR appeals.
• Coordinates worklists and completion of cases on audit review, retro authorization and appeals.

Northside Hospital is an award-winning and state-of-the-art healthcare provider that is constantly growing. They are expanding the quality and reach of their care to patients and communities, creating more opportunity for healthcare professionals in Atlanta and beyond.