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• Conduct telephonic case management and thorough assessments of patients' physical, psychosocial, and financial needs.
• Develop and monitor treatment plans in collaboration with patients, caregivers, and multidisciplinary teams.
• Negotiate cost management strategies and maintain detailed documentation while meeting productivity and quality standards.

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 and health plans with data-driven solutions and are on a mission to empower people to lead healthier lives.

• Conduct comprehensive clinical assessments and develop individualized care plans for high-risk members.
• Coordinate transitions of care and collaborate with interdisciplinary team members including Community Health Workers and providers.
• Provide health coaching and disease management education to help members achieve their health goals.

Zócalo Health is a tech-enabled, community-oriented primary care organization serving historically underserved populations. Founded in 2021 and backed by leading healthcare investors, it is scaling rapidly with a culture focused on value-based, whole-person care.

• Manage patient physiological markers and provide clinical triage.
• Conduct wellness calls and collaborate with care teams to set health goals.
• Drive patient engagement and ensure adherence to RPM program standards.

Vivo Care is building a platform to make healthcare continuous, personal, and truly connected. It is a fast-growing startup with a culture of inclusion, collaboration, and innovation.

• Collaborate with physicians, APPs, and interdisciplinary team members to manage a patient panel and address specialized needs post-hospitalization.
• Perform assessments and develop comprehensive care plans based on individual patient values, goals, and preferences.
• Coordinate patient care delivery with clinicians, network providers, contracted vendors, and community-based services.

Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic approach. The company provides interdisciplinary clinical resources and analytical tools to improve patient outcomes, operating with a team that values innovation and comprehensive care.

• Build meaningful relationships with patients and families to understand their goals and barriers.
• Create personalized care plans addressing medical, behavioral, and social needs.
• Coordinate care across providers and settings, ensuring safety, quality, and continuity.

Guidehealth is a data-powered, performance-driven healthcare company dedicated to making great healthcare affordable and improving patient health. As a physician-led organization with a high degree of agility, it employs a remote team and fosters a collaborative, mission-driven culture focused on continuous learning.

• Coordinate patient care remotely using phone or video, focusing on assessments, care plans, and resource access.
• Identify process improvements through data collection and auditing, while navigating multiple EHR platforms.
• Utilize home health expertise to triage patient needs and maintain open communication with patients, caregivers, and providers.

ThedaCare is a community health system consisting of seven hospitals and numerous clinics, serving as the third largest health care employer in Wisconsin. With approximately 6,800 employees, the organization emphasizes innovation, compassion, and a commitment to improving community health.

• Provide case management addressing medical, social, psychological, physical, and spiritual needs of members.
• Develop, implement, and monitor care plans in collaboration with PCP, caregivers, and team members.
• Ensure members' needs are met through coordinated care and support.

Elderplan offers Medicare and Medicaid managed care health plans designed to keep members independent and living life on their own terms. As part of MJHS, it is a supportive community committed to excellence, respect, and high-quality personalized health care services.

• Act as a liaison for a patient panel of medically stable patients, coordinating care between internal and external providers.
• Monitor and triage lab orders and results, providing education and medical management support to patients and families.
• Triage emergent issues in a time-sensitive manner and coordinate care with hospitals for medical stabilization admissions.

Equip is the leading virtual, evidence-based eating disorder treatment program on a mission to ensure everyone with an eating disorder can access treatment that works. Founded in 2019, the company is fully virtual and has been recognized as one of the most influential companies of 2023, with a diverse and passionate team.

• Deliver virtual, patient-centered care with empathy and clinical excellence.
• Triage patient concerns using evidence-based protocols and sound clinical judgment.
• Coordinate laboratory follow-ups, referrals, and diagnostic services across the care team.

MyLaurel is a healthcare organization delivering virtual acute care support to vulnerable patients. They are a collaborative, high-performing team focused on transforming healthcare delivery.

• Provide telephonic and virtual support via inbound/outbound calls, email, chat, and text for patients prescribed complex neurological therapies.
• Educate patients about treatment/therapy, connect them with resources, and collaborate with Field Nurse Educators and HUB partners to ensure continuity of care.
• Identify barriers to therapy adherence using motivational interviewing, maintain compliant documentation, and report Adverse Events per policy.

Momentum Life Sciences partners with life science companies to design and deliver patient support programs that help patients start and stay on therapy. With over 30 years in healthcare and a patient engagement platform combining human and digital interventions, they are a leading provider of engagement solutions.

• Manage the member's clinical experience from request through desired outcome, including account activation and medical history drafting.
• Coordinate video or phone consults with specialists and schedule monitors in advance, troubleshooting issues as needed.
• Conduct ongoing follow-up post-consult and facilitate local recommendations, communicating with primary care physicians or specialists.

Transcarent is a health and care platform that combines medical, pharmacy, and point solutions with a generative AI-powered experience for health consumers. With over 1,700 employer and health plan clients serving 21 million Members, they foster a culture of People First, Care, Resilience, Results, and Humble and Human.

• Serve as the primary point of contact for physicians, clinics, and healthcare stakeholders, ensuring consistent communication and trusted relationships.
• Support healthcare providers in navigating patient assistance programs, including enrollment, reimbursement, and therapy access processes.
• Manage and complete all required documentation such as special authorizations, prescription renewals, and enrollment forms with accuracy and timeliness.

Jobgether is an AI-powered job matching platform that connects candidates with hiring companies. They use technology to ensure fair and efficient recruitment processes, and foster inclusive employee programs.

• Serve as the main point of contact for patients and families transitioning from or seeking post-acute services.
• Make clinical level-of-care determinations using discussions, medical records, and other clinical data.
• Provide patient education on home health, hospice, palliative care, Medicare coverage, and billing.

Gentiva is a national leader in hospice, palliative, and home health care, providing compassionate care to patients in their homes. With nearly 600 locations and thousands of clinicians across 38 states, they offer a collaborative environment where inspiring achievements are recognized.

• Monitor a specific group of patients and support them in achieving short and long term health goals.
• Coordinate with providers to ensure patients' needs are met through remote monitoring technology.
• Manage patient onboarding, device setup, data management, and quality assurance for remote monitoring programs.

Optima Medical is an Arizona-based medical group consisting of 30 locations and over 130 medical providers, caring for more than 200,000 patients statewide. Their mission is to help communities 'Live Better, Live Longer' through personalized healthcare, with a focus on preventing leading causes of death.

• Facilitate conversations and collaboration between interdisciplinary care teams to ensure a seamless patient experience.
• Support scheduling, make reminder calls, and handle operational tasks for the care coordination team.
• Answer patient calls, escalate issues, and request necessary documentation from patients and providers.

Tuesday Health is a value-based palliative care provider group dedicated to transforming serious illness and end-of-life care. They are a growing company with an interdisciplinary team that fosters an inclusive environment.

• Assess member needs and oversee development of client care plans
• Connect clients to social services and advocate with healthcare professionals
• Complete documentation and maintain patient health records in EMR system

Vynca provides comprehensive care for more quality days at home for individuals with complex needs. They are a close-knit community operating with core values of Excellence, Compassion, Curiosity, and Integrity.

• Conduct patient enrollment, outreach, and engagement via text and phone to support chronic care management.
• Ensure documentation and billing compliance according to Medicare CCM requirements.
• Coordinate care transitions, referrals, and follow-up appointments with providers and patients.

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

• Process referrals to MTM team and schedule appointments for patients.
• Provide phone support and document patient information in electronic health records.
• Assist with prior authorizations and billing to help patients access affordable medications.

UnityPoint Health is a healthcare system providing medical services. It is recognized as a Top 150 Place to Work in Healthcare and offers a supportive culture for team members.

• Perform case reviews and process requests for elective services and durable medical equipment.
• Collaborate with physicians, vendors, and providers to ensure regulatory compliance and timely service.
• Provide high-quality customer service to members and healthcare professionals.

Elderplan provides Medicare and Medicaid managed care health plans designed to help people stay independent. They are part of MJHS, a supportive community committed to excellence, respect, and collaboration.

• Perform concurrent and retrospective reviews on all facility and appropriate home health services.
• Monitor level and quality of care and proactively manage acutely and chronically ill patients.
• Act as liaison to Plan Medical Director and coordinate interdisciplinary approach.

Curana Health is a national leader in value-based care for senior living communities and skilled nursing facilities. Founded in 2021, they serve 200,000+ seniors in 1,500+ communities across 32 states with a team of over 1,000 clinicians.