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.
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.
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.
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.
Provides quality driven telephonic clinical assessments, health education, and utilization management services.
Provides assessments to individuals using telecommunications in accordance with computer-based algorithms, protocols, and guidelines.
Uses clinical knowledge to assess, disposition, make recommendations for care, provide education and health information.
Carenet Health values the expertise and dedication of their team members. They are committed to offering an appealing compensation package and creating an inclusive environment for all employees.
Conduct outbound telephone outreach to patients and engage patients in pharmacist-led consultations.
Serve as a liaison between patients and pharmacies to resolve medication barriers.
Collaborate closely with Care Management Pharmacists to support medication adherence initiatives.
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.
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.
Proactively outreach to patients via phone to educate them on the care services available to them.
Meet or exceed performance targets defined as “completed first visits” on a daily basis.
Research and update patient information, leveraging internal and external data platforms, including EHRs and local market resources.
Strive Health strives to transform the broken kidney care system through early identification, engagement, and comprehensive coordinated care. They are an organization that embraces diversity and supports each other and is the destination for top talent in healthcare.
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.
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.
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.
HealthCheck360 focuses on reducing medical costs while increasing employee engagement and productivity. They accomplish this by providing onsite biometric screenings, engaging participants through technology and programming, educating the participant with risk-specific targeted communications, and supporting positive behavior change through Health Coaching and Condition Management programs.
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.
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.
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 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.
Deliver patient centric health coaching that integrates medical needs with patient preferences.
Triage patient reported symptoms and side effects according to internal protocols, escalating to Providers when appropriate.
Provide comprehensive diabetes, hypertension, hyperlipidemia, and weight management care and education via chat, phone, and video.
9amHealth is a specialized cardiometabolic care provider, offering custom care plans, prescription medications, and expert guidance to help members live healthier. They are a San Diego, California-based company with a small, flexible team and are backed by 7Wire Ventures, Human Capital, Founders Fund, and Define Ventures.
Use technology to remotely monitor patients' health and provide necessary interventions based on patient data.
Monitor patient vital signs, including blood pressure, blood glucose, oxygen saturation, body weight and temperature.
Collaborate with healthcare providers to develop and implement the best possible care and support.
CardioOne partners with independent cardiologists to provide innovative solutions that improve patient outcomes and reduce costs. They foster a culture of employee engagement that translates into an exemplary patient experience, having partnered with WindRose Health Investors to grow their team.
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.