Source Job

• Managing the overall care management of patient panel by leveraging experience, expertise, and knowledge in both the nursing field and value-based care operations.
• Establishing trusting and empathetic relationships with patients and families to provide clinical and emotional support and foster collaboration throughout their care journey.
• Serving as an advocate and community liaison for patients to ensure proper and timely resources and support while navigating the health care system after hospitalization and maintaining compliance with the primary care team’s/nephrologist’s treatment plan.

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 quality of life by delaying disease progression, shifting care to the home, and accelerating kidney transplants.

• 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.

• Manages a defined patient panel with accountability for quality, cost and outcomes.
• Obtains patient history, performs physical exam, orders and interprets diagnostic tests and formulates a plan for individual patient short-term and longitudinal needs.
• Serves patients and performs patient visits in multiple care settings a including patient home, telehealth visits or dialysis clinics/partner MD space (where applicable).

Strive Health is on a mission to transform chronic conditions by identifying risk earlier, coordinating thoughtful care, and supporting people through every stage of their health journey. They are composed of passionate Strivers who care deeply about making an impact and show up for one another as One Team.

• 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.

• 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.

• 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.

• 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.

• Coordinate and implement medical case management to facilitate case closure.
• Assess appropriate utilization of medical treatment and services.
• Review medical records and assess data to ensure appropriate case management process.

Berkley Medical Management Solutions (BMMS) provides managed-care service for W.R. Berkley Corporation, focusing on injured worker’s return to work. BMMS was started in 2014 and combines clinical practices, return-to-work strategies, and software for workers’ compensation cases.

• 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.

• 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.

• Triage patient care needs over the phone, providing medical advice, and coordinating with healthcare providers to address urgent concerns.
• Use motivational interviewing and active listening skills to understand patient needs and effectively communicate to identify/resolve issues.
• Implement strategies to prevent hospital re-admissions, including patient education, follow up telephonic touchpoints, and care coordination.

VitalCaring is a leading provider of home health and hospice services. Founded in 2021, it has over 65 locations across the country and is committed to fostering a culture of support, growth, and excellence for its team.

• 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.

• Manage communications between patients and doctors and associated documentation.
• Collaborate with Customer Service to troubleshoot patient requests pertaining to physician requirements.
• Provide clinical feedback in response to patient inquiries involving medication, lab, side effects.

Hone is an online medical clinic transforming healthcare and enhancing longevity. They use scientific advancements to empower individuals to take control of their health. Hone is a remote-first employer with a focus on people and a culture that values collaboration and joy.

• Serve as the remote support hub for Nurse Practitioners (NPs) practicing in Skilled Nursing Facilities (SNFs).
• Improve NP efficiency and patient outcomes by owning clinical, data, and communication tasks.
• Perform clinical triage, educate families, manage program data, and coordinate complex care.

HealthDrive delivers on-site dentistry, optometry, podiatry, audiology, behavioral health, and primary care services to residents in long-term care, skilled nursing, and assisted living facilities. They connect patients in need of vital healthcare to doctors committed to dignity and excellence.

• 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.

• 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.

• 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.

• 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.

• 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.