Care Coordinator - Central Time Zone Remote

Primary Functions:

• Perform telephonic outreach to enroll and engage patients.
• Establish connection as primary point of contact for enrolled patients.
• Facilitate seamless transitions of care across care settings and dialysis centers.

Social Determinants of Health:

• Conduct thorough patient assessments to identify social, economic, and environmental factors.
• Connect members to resources such as housing assistance and transportation.
• Identify barriers to care and work to address inequities in health access.

Documentation and Reporting:

• Maintain open communication with patients, families, caregivers and healthcare teams.
• Ensure accurate documentation of member interactions and assessments.
• Provide educational resources to patients and their families.