Conduct timely post-discharge follow-up calls with patients after inpatient visits to assess needs and reinforce the plan of care.
Review and reconcile discharge medications and escalate any concerns to the Primary Care Provider.
Assist in coordinating and/or scheduling follow-up appointments with the patient's Primary Care Provider and/or specialists
Privia Health is a technology-driven physician enablement company that collaborates with medical groups, health plans, and systems. They optimize physician practices, improve patient experiences, and reward doctors for delivering high-value care. The company is led by top industry talent and exceptional physician leadership.
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.
Conducts outbound and inbound calls to educate patients about Advanced Care Planning ultimately scheduling an appointment.
Overcome Patient concerns and objections by clearly articulating the importance of Advanced Care Planning and how it benefits their healthcare journey.
Respond to multimodal and outgoing calls, texts, and emails by providing direction to Patients’ questions and/or concerns.
Aledade exists to empower independent primary care by creating value-based contracts across a wide variety of health plans. They were founded in 2014 and have become the largest network of independent primary care in the country. They have a collaborative, inclusive, and remote-first culture.
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.
Proactively outreach to patients via phone to educate them on the care services available to them.
Meet or exceed performance targets defined as “completed first visits” on a daily basis.
Research and update patient information, leveraging internal and external data platforms, including EHRs and local market resources.
Strive Health strives to transform the broken kidney care system through early identification, engagement, and comprehensive coordinated care. They are an organization that embraces diversity and supports each other and is the destination for top talent in healthcare.
Conduct timely post-discharge follow-up calls with patients after inpatient visits to assess needs and reinforce the plan of care.
Review and reconcile discharge medications and escalate any concerns to the Primary Care Provider.
Assist in coordinating and/or scheduling follow-up appointments with the patient's Primary Care Provider and/or specialists.
Privia Health is a national physician platform transforming the healthcare delivery experience by providing tailored solutions for physicians and providers. They create value and secure the future through high-performance physician groups, accountable care organizations, and population health management programs.
Serves as a primary point of contact for members, caregivers, and providers regarding nurse appointments and care coordination activities.
Coordinates and schedules nurse case management activities, including assessments, follow-ups, and interdisciplinary care team meetings.
Supports accurate documentation by ensuring required scheduling and encounter-related data is entered into designated systems.
Fallon Health is dedicated to providing equitable, high-quality, coordinated care to its members and is consistently recognized as a top health plan for member experience, service, and clinical quality. With roots dating back to 1977 in Worcester, Massachusetts, they focus on government-sponsored health insurance programs and value diversity and inclusion.
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.
Conduct outbound telephone outreach to patients and engage patients in pharmacist-led consultations.
Serve as a liaison between patients and pharmacies to resolve medication barriers.
Collaborate closely with Care Management Pharmacists to support medication adherence initiatives.
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.
Assess, plan, coordinate, and monitor patient care.
Develop, implement, and monitor individualized care plans.
Coordinate care across providers, facilities, and community resources.
Limitlessli specializes in recruiting, hiring, and managing high-caliber remote staff for dynamic and growing healthcare facilities. They connect clients with highly qualified professionals, offering tailored services to meet unique business needs, leveraging an extensive global network.
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!
Deliver patient centric health coaching that integrates medical needs with patient preferences.
Triage patient reported symptoms and side effects according to internal protocols, escalating to Providers when appropriate.
Provide comprehensive diabetes, hypertension, hyperlipidemia, and weight management care and education via chat, phone, and video.
9amHealth is a specialized cardiometabolic care provider, offering custom care plans, prescription medications, and expert guidance to help members live healthier. They are a San Diego, California-based company with a small, flexible team and are backed by 7Wire Ventures, Human Capital, Founders Fund, and Define Ventures.
Conduct high-volume outbound and inbound calls with patients, providers, and pharmacies.
Collaborate with patients to identify and remove barriers to medication adherence.
Accurately document all interactions, outcomes, and identified barriers in appropriate systems.
Aledade empowers independent primary care practices. They were founded in 2014 and have become the largest network of independent primary care in the country, with a collaborative, inclusive, and remote-first culture.
Serve as primary contact for patients, families, and providers
Schedule and coordinate medical appointments
Manage patient documentation and EMR updates
Pine Park Health is a value-based primary care practice redesigning how residents of senior living communities get or stay healthy and lead a life they love. They've expanded to over 185 communities across Arizona, California, and Nevada with investments from firms like First Round Capital and Google’s AI fund.
Engage and enroll eligible health plan members in supportive care services.
Educate members on Tuesday Health’s service offerings and support ongoing engagement.
Provide ongoing telephonic customer service to members and their caregivers.
Tuesday Health is a value-based palliative care provider group dedicated to transforming serious illness and end-of-life care. They deliver goal-centered care focused on alleviating physical symptoms and emotional stress for individuals and their caregivers and are shaping the future of community-based palliative care nationwide.
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.
Facilitate collaboration with health plan care managers
Tuesday Health is a value-based palliative care provider group dedicated to transforming serious illness and end-of-life care. They deliver goal-centered care focused on alleviating physical symptoms and emotional stress for individuals and their caregivers.
Provide case management to members including medical, social, psychological, physical, and spiritual needs.
Develop, implement, and monitor the care plan in conjunction with the PCP, caregivers, and other team members.
Help meet the member's needs.
Elderplan and HomeFirst are Medicare and Medicaid managed care health plans that are expanding services in response to patients' needs. At MJHS, they are a supportive community committed to excellence, respect, and providing high-quality, personalized health care services.
Managing the care of patient panel by leveraging experience and knowledge.
Establishing relationships with patients and families to provide support.
Serving as an advocate and community liaison for patients.
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach. We are committed to improving patient outcomes and quality of life by delaying disease progression and shifting care to the home.