Conduct outbound telephonic patient outreach and provide one-on-one coaching and support to patients managing chronic conditions.
Help patients execute personalized care plans and achieve their goals by providing education and coaching focused on behavior modification, nutrition, physical activity, and self-management strategies.
Document patient interactions, outcomes, and follow-up plans in the Cadence platform; identify barriers to care and connect patients with resources or internal support pathways.
Cadence is a clinical AI company that delivers continuous, proactive care for older adults with chronic conditions. They pair patients with a dedicated clinical team, integrate deeply into health system EMRs and workflows, and use their Clinical Intelligence platform.
Conduct compassionate advance care planning conversations with patients.
Educate patients and families about medical interventions in understandable terms.
Accurately document conversation details to generate state-specific advance care planning documents.
Aledade empowers independent primary care practices. Founded in 2014, they've become the largest network of independent primary care in the country and have a collaborative, inclusive and remote-first culture.
Pulling, sorting, and analyzing data to determine member eligibility for the Population Health management Program.
Coordinating and providing care that is timely, effective, equitable, safe, and member-centric while following HMO processes.
Managing case assignments which includes outreach, documentation, monitoring for case progression, and case closure.
Guidehealth is a data-powered healthcare company dedicated to operational excellence. They aim to make healthcare affordable, improve patient health, and restore fulfillment in practicing medicine. Guidehealth is a growing and innovative organization and employees are expected to adapt to evolving business needs.
Conduct new patient visits via telemedicine, focusing on chronic condition management.\n- Collaborate with RNs to develop individualized care plans tailored to patients' needs.\n- Perform telemedicine visits for ailments experienced by residents in senior living communities.
Red Cell Partners is an incubation firm building and investing in rapidly scalable technology-led companies that are bringing revolutionary advancements to market in healthcare, cyber, and national security. United by a shared sense of duty and deep belief in the power of innovation, Red Cell is developing powerful tools and solutions to address our Nation’s most pressing problems.
Providing remote health coaching to members at risk for chronic kidney disease or have chronic kidney disease.
Working in partnership with participating members to increase their understanding and management of conditions that impact kidney health.
Establishing and maintaining contact with assigned and active members via video, phone, text, and email.
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 they have a 96% client retention rate.
Communicate and provide education to members and providers on insurance plan benefits and digital health solutions.
Employ active listening & motivational interviewing skills, and can handle difficult calls tactfully, courteously, professionally and document accordingly that can build patient trust and engagement.
Accurately track and document work on a variety of internal software tools and platforms.
Evry Health is on a mission to bring humanity to health insurance. They are a high-technology health plan that expands benefits, increases access and transparency, and features a personalized, human approach. Evry Health is the major medical division of Globe Life (NYSE:GL) with more than 3,000 corporate employees and 15,000 agents.
Works with field staff and Manager, Clinical Services (MCS) to appropriately schedule clinicians for cases in assigned areas of responsibility.
Communicates appropriately regarding changes in schedule or service delivery.
Demonstrates the ability to be efficient and productive by organizing job duties and responsibilities.
CommonSpirit Health at Home is a full-service health care organization that believes the best place for someone to get better is in their own home. As a faith-based organization, we are committed to finding new ways to improve the health of our patients and the health of the communities we serve.
Responsible for conducting monthly clinical check-ins, identifying and addressing clinical concerns.
Reinforcing care plans, escalating issues appropriately, and ensuring clinical documentation accuracy.
Supporting patients between office visits while collaborating closely with Evergreen’s providers, care teams, and leadership.
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.
Monitor and interpret patient vitals, assessments, and alerts within Welby Health’s platform.
Develop, implement, and adjust individualized care plans that address both clinical and social needs.
Deliver patient education and coaching via telephone and secure messaging.
Welby Health is committed to transforming the way complex conditions are managed. They aim to advance patient outcomes by integrating efficient care coordination, data-driven insights, and enhanced communication across the care continuum. Welby Health is headquartered in San Diego.
Coordinate care and collaborate with multiple disciplinary team members to improve the quality of care and clinical outcomes.
Conduct thorough assessments to determine unmet needs and develop individualized care plans.
Promote quality cost-effective outcomes with the goal of improved care coordination.
Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services. They strive to create purposeful work settings where staff can provide great care, while advancing in knowledge and experience through challenging work assignments and stimulating relationships.
Manage daily hospital census of engaged members, reviewing alerts and updating information in the EMR system.
Communicate with hospital/discharge planners, notifying patients of WellBe's awareness of their hospitalization, and track admissions.
Engage in telephonic conversations with patients and families, explaining the WellBe program and aiming to schedule post-discharge appointments.
WellBe is pioneering a new way of healthcare that is revolutionizing the industry. They have a patient-focused environment that ensures patients can live a fulfilling life, offering growth and development opportunities across expanding markets and celebrating success globally.
Maintain ongoing caseload of individuals through the utilization of evidence based approaches to promote engagement and achievement of health goals
Use relationship-based strategies to support members with social support navigation, understanding that many may have lived personal experiences causing them to be initially hesitant or distrusting of the health care system
Conducts periodic telephonic and SMS outreach to ensure timely follow-up to members
Pair Team is an innovative, mission-driven company reimagining how Medicaid and Medicare serves underserved populations. As a tech-enabled medical group, they deliver whole-person care by partnering with organizations deeply connected to communities.
Conduct IOP orientations for new patients, introducing program structure, expectations, and resources.
Lead discharge planning beginning at admission, ensuring linkage to outpatient providers, community resources, and payor-approved step-down services.
Track engagement, discharge, and readmission metrics; report trends to the Clinic IOP Director for quality-improvement initiatives.
Salma Health is reimagining brain healthcare by bringing together advanced diagnostics, evidence-based treatments, and continuous support under one connected system. Their multidisciplinary team delivers personalized care for people living with brain and mental health conditions.
Evaluates member health metrics and professional resources to inform UM/CM initiatives and programs.
Refers members and providers to G.E.H.A resources and programs, as indicated, maximizing their health plan benefits.
Monitors and evaluates program effectiveness, tracks relevant metrics, and reports outcomes.
Government Employees Health Association (G.E.H.A) is a nonprofit member association providing health and dental benefits to millions of federal employees and retirees since 1937. G.E.H.A is headquartered in Lee's Summit, Missouri, offering hybrid and work-from-home options for many roles.
Answer calls and resolve questions, routing to appropriate departments.
Complete documentation in EMR and marketing systems, including initial prescreening.
Schedule new and returning patients and complete follow-up duties.
Pyramid Healthcare provides addiction treatment, mental health recovery, and eating disorder treatment. They focus on client-centered care and offer supportive environments that help patients overcome life’s challenges.
Provide high-quality virtual primary care through video visits, including assessment, diagnosis, treatment, and patient education.
Manage a panel of patients, delivering comprehensive care across acute, chronic, and preventive needs.
Collaborate with the Care and Case Management team to develop care plans and support successful outcomes.
Included Health delivers integrated virtual care and navigation, aiming to raise the standard of healthcare for everyone. The company breaks down barriers to provide high-quality care for every person, offering care guidance, advocacy, and access to personalized virtual and in-person care.
Provide health assessments and treatment solutions via telephone, video, or chat functions.
Receive inbound phone calls from patients seeking answers to various medical conditions.
Stay up to date with current health trends and recommendations.
PWNHealth is a national clinician network improving early disease detection and prevention using advanced diagnostics and telehealth, serving all 50 states and Puerto Rico. They are a mission-driven company with a positive culture, backed by leading growth equity firms Spectrum Equity and the Blue Venture Fund (BVF).
Collaborate with interdisciplinary team members to deliver comprehensive virtual care services to patients.
Provide support for patients and families coping with life transitions, chronic illnesses, and other psychosocial challenges.
Develop and implement individualized care plans that address patients' needs, connecting them with relevant community resources.
Interwell Health is a kidney care management company that partners with physicians. They aim to reimagine healthcare and set the standard for the industry to help patients live their best lives. They are committed to diversity, equity, and inclusion throughout their recruiting practices.
Responsible for professional nursing skills to provide personalized high-touch telephonic support to patients.
Provide clinically relevant individualized education in conjunction with product support.
Partner closely with cross-functional stakeholders to ensure continuity of care and escalation as appropriate across teams.
Momentum Life Sciences helps the healthcare industry connect, motivate, and empower people to engage in their health. We are a leading provider of patient and healthcare professional engagement solutions with more than 30 years of experience in the healthcare industry.
Serve as an expert diabetes health coach, supporting individuals to achieve the best health outcomes possible.
Engage members with empathy and care via telephone calls and text messaging.
Deliver education and personalized guidance according to Perry Health protocols to help members better self-manage their condition and adhere to their care plan.
Perry Health is rethinking chronic care through a fully remote, continuous care model. They provide expert diabetes education and clinical management for Medicare patients, delivered by a comprehensive team of specialized CDCES Registered Nurses, Registered Dietitians, and Accountability Coaches.