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.
Build trusting relationships with patients, families, and providers, addressing health questions and care needs.
Identify medical, behavioral, social, emotional, and financial needs to support whole‑person care.
Strengthen the connection between patients and healthcare providers by addressing barriers and facilitating communication.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence, with the goal to make great healthcare affordable, improve patient health, and restore fulfillment for providers. They leverage remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers.
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.
Build trusting, ongoing relationships with patients, families, caregivers, and medical/behavioral health providers.
Engage high‑risk or targeted patient populations using bi-directional communication to address health questions, concerns, and care needs.
Accurately and promptly document all interactions, assessments, and interventions in the electronic health record (EHR) and Guidehealth documentation systems.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers.
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.
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.
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.
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.
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.
Provides non-clinical administrative support to Case Managers and Care Coordinators.
Obtains and manages medical documents, ensuring accurate record retrieval.
Prioritizes tasks based on expedited requests with attention to detail.
Spectrum Healthcare Resources (SHR) delivers systems and processes designed to meet the unique needs of Military and VA Health Systems. They provide physician and clinical staffing and management services to United States Military Treatment Facilities, VA clinics and other Federal Agencies.
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. They aim to dramatically improve healthcare for seniors with a new model designed around patients, families, community staff, providers, and payers.
Act as a Gentiva representative supporting patients seeking post-acute care.
Navigate healthcare options, including post-acute offerings and Medicare coverage.
Assist in the admissions process by coordinating with Gentiva branch staff.
Gentiva offers compassionate care in the comfort of patients' homes and is a national leader in hospice care, palliative care, home health care, and advanced illness management. They have nearly 600 locations and thousands of dedicated clinicians across 38 states, fostering a collaborative environment.
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, 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 provide high-technology health plans that expand benefits, increase access and transparency, and feature a personalized, human approach. Evry Health is the major medical division of Globe Life (NYSE:GL), which has 16.8 million policies in force, and more than 3,000 corporate employees and 15,000 agents.
Manage provider schedules and prepare charts for upcoming home visits.
Conduct outreach for scheduling, appointment confirmation, and wellness checks for high-risk members.
Obtain medical records, submit referral authorizations, and coordinate lab orders and transportation for members.
Alignment Health is dedicated to reshaping senior care, empowering members to age gracefully and live vibrantly. Their mission-driven team strives to deliver high-quality, affordable care to members daily.
Serves as a liaison between service providers and assists with enrollment in community resources.
Completes applications for resources and paperwork for provider visits.
Follows up and tracks referrals and outcomes for pharmacy, DME, and home care.
Strive Health aims to transform the kidney care system through early identification and comprehensive coordinated care. They integrate with local providers, embrace diversity, and support each other, making Strive a great destination for top talent in healthcare.
Complete Comprehensive Health Evaluations (CHEs) to assess and manage comorbid conditions while addressing medical, social, emotional, and financial needs.
Manage CKD and ESKD patients, focusing on slowing disease progression, reducing costs, and preventing readmissions.
Lead the clinical team to ensure care coordination aligns with medical treatment plans and addresses both medical and psychosocial needs.
DaVita is a comprehensive kidney care provider focused on transforming care to improve the quality of life for patients globally. As of March 31, 2022, DaVita served 200,800 patients at 2,809 outpatient dialysis centers in the U.S.
Play an active role in member registration and enrollment, including organizing community engagement and outbound outreach calls/texts.
Engage with a panel of assigned members to provide care navigation, appointment logistics, prescription drug support, lab support, referral coordination, care plan adherence support, and resource sharing.
Serve as the primary relationship holder for members with behavioral health needs; provide consistent outreach, follow-up, and re-engagement support, including after ED/inpatient discharge when applicable.
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. They combine local, community-based teams with virtual care and modern technology to deliver coordinated, whole-person care where members live and receive support.
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.
Assess member needs in physical health, mental health, and social supports.
Oversee the development of client care plans and goal settings.
Connect clients to social services, advocate for their needs, and ensure documentation.
Vynca is dedicated to transforming care for individuals with complex needs, fostering a close-knit community committed to caring for each other and the people they serve. Guided by core values like excellence and compassion, Vynca empowers employees to make a profound difference in providing comprehensive care for more quality days at home.
Identifying caregiver availability and staffing new cases efficiently.
Updating all relevant systems with caregiver availability and case details.
Assigning caregivers to cases and verbally reviewing all patient details, duties, special requirements, travel time, and expectations.
SnappyCX is a dynamic and innovative company at the forefront of the BPO industry providing talent outsourcing. They redefine the benchmarks for excellence in talent-centric solutions.