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.
Conduct telehealth assessments that set the foundation for months of coordinated geriatric care.
Confirm Medicare eligibility, synthesizing complex medical and social history, identifying the barriers to treatment.
Establish the trust that families need to engage fully, informing the entire care strategy.
Hera is dedicated to care management in the community for older adults, covered by Medicare. They match every family with a dedicated Hero, who has the tools, time, and autonomy to help, providing real, ongoing support.
Serve as the first line of support for residents and facility staff after-hours, providing direction and medical care over the phone.
Use Curana’s telephonic platform to take and place calls, coordinating care between facilities, hospitals, and clinics.
Deliver high-quality, cost-effective care to patients—addressing acute, chronic, and behavioral health needs in collaboration with physicians and specialty providers.
Curana Health is dedicated to radically improving the health, happiness, and dignity of older adults. They are a national leader in value-based care, serving 200,000+ seniors in 1,500+ communities across 32 states with a team of more than 1,000 clinicians.
Conduct new patient and establish-care visits via telemedicine, focusing on chronic condition management.
Collaborate with on-site RNs to develop individualized care plans tailored to patients' chronic disease burdens.
Perform telemedicine priority care visits for common ailments experienced by residents in senior living communities.
Savoy Life is a distributed senior living platform focused on bridging the gap between senior living communities and healthcare. With a team of specialized clinicians, including nurses and geriatricians, Savoy Life offers a tech-enabled solution that empowers senior living operators.
Serve as the first line of support for residents and facility staff after-hours, providing direction and medical care over the phone.
Use Curana’s telephonic platform to take and place calls, coordinating care between facilities, hospitals, and clinics.
Deliver high-quality, cost-effective care to patients—addressing acute, chronic, and behavioral health needs in collaboration with physicians and specialty providers.
Curana Health is dedicated to radically improving the health, happiness, and dignity of older adults. They are a national leader in value-based care, serving 200,000+ seniors in 1,500+ communities across 32 states with a team of more than 1,000 clinicians.
Conduct comprehensive health assessments via telehealth
Review patient history, medications, and preventive needs
Educate members on next steps and close HEDIS care gaps
EasyHealth is dedicated to providing thorough health assessments and preventive care solutions to ensure patients achieve and maintain optimal health. They partner with health plans and risk-bearing entities to enable value-based care and are committed to providing an environment of mutual respect and equal employment opportunities.
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.
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.
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.
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.
Provide exceptional care, disease management and health education to patients
Support goal setting for individual patients asynchronously to help them better manage their chronic conditions
Create personalized action plans with guidelines to reduce or eliminate unwanted behaviors
Salvo is focused on chronic gut health and metabolic conditions from IBS to obesity, assigning patients a care team and providing app-based care seven days a week. Salvo is backed by leading health care investors from innovators; they offer a culture that drives constant innovation and is marked by relentless curiosity and a sense of empathy.
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.
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.
Provide longitudinal telehealth care for patients with obesity.
Collaborate with physicians and registered dietitians to deliver exceptional team-based care.
Committed to the highest quality of medical care and an evidence-based approach to obesity management
Form Health is a virtual obesity medicine clinic delivering multi-disciplinary evidence-based obesity treatment through telemedicine. Founded in 2019, Form Health is a venture-backed innovative startup with an experienced clinical and leadership team and is deeply invested in their core value to put patients first.
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!
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.
Handle inbound calls from patients and caregivers, providing compassionate and informed triage.
Assist with finding appropriate providers, community resources, and care solutions and coordinate priority virtual appointments.
Research information online and in Privia’s internal knowledge databases to make the most appropriate triage and care advice decisions.
Privia Health is a technology-driven, national physician enablement company that collaborates with medical groups, health plans, and health systems. They optimize physician practices, improve patient experiences, and reward doctors. Their platform is led by top industry talent and consists of scalable operations.
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.
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.