In this role, you will support a complex and expanding patient population while working closely with cardiologists and advanced practice providers.
Daily responsibilities include communicating with patients through telephone outreach, MyChart messaging, and in‑person interactions during clinic visits.
The Nurse Clinician will work in a multidisciplinary environment which will require exceptional interpersonal skills to establish and maintain effective relationships with patients, physicians, clinical and administrative units.
Conduct patient onboarding via phone, explaining program goals.
Receive follow-up calls and document information in charting systems.
Communicate concerns and changes in condition to the Provider Team.
CopilotIQ + Biofourmis is transforming in-home care with the industry's first AI-driven platform for pre-surgical optimization to chronic care. With commitment to enhancing the lives of seniors with chronic conditions and advanced data-driven insights, they're setting a new standard in accessible healthcare.
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.
Responsible for planning, directing, providing, and documenting appropriate care for patients in the designated care setting
Assists in coordinating comprehensive care for patients, including assisting with the consent process, data collection and arranging any required follow-up visits, referrals, testing, treatment, and/or long-term follow-up
Works collaboratively with the interdisciplinary team to coordinate on-going care, focused on cost-effective ways to maximize wellness and enhance patients’ lives
At Northwestern Medicine, every patient interaction makes a difference in cultivating a positive workplace. As an integral part of our team, you'll have the opportunity to join our quest for better health care, no matter where you work within the Northwestern Medicine system.
Own all patient communication, including outreach, engagement, data entry into internal and external systems, scheduling, appointment coordination, pre-authorizations, and billing follow-up
Schedule virtual visits and outpatient procedures (such as stress tests, echocardiograms, and cardiac calcium scoring) with both Heartbeat and third parties
Follow up with patients via email, phone, and/or text to drive patient engagement
Heartbeat Health is a virtual-first cardiovascular care company, providing patients with convenient, high-quality heart care. They leverage real-time data and AI-powered insights, empowering providers and patients with personalized treatment plans.
Rapidly assess and prioritize patients' healthcare needs.
Conduct patient interviews, evaluate symptoms, and perform initial assessments.
Provide advice, educate, and coordinate care.
Virginia Mason Franciscan Health provides exceptional healthcare. They have a comprehensive network of 10 hospitals and nearly 300 care sites across the greater Puget Sound region.
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.
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.
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.
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.
Consistently practices Patients First philosophy and adheres to high standards of customer service.
Correctly identifies and collects patient demographic information in accordance with organization standards.
Uses effective service recovery skills to solve problems or service breakdowns when they occur.
At Northwestern Medicine, every patient interaction makes a difference in cultivating a positive workplace, setting it apart as a leader in the healthcare industry. As an integral part of the team, you'll have the opportunity to join our quest for better health care, with competitive benefits from tuition reimbursement and loan forgiveness to 401(k) matching.
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.
Provides telephone and walk-in triage to patients seeking advice and medical services.
Teaches and counsels patients and families concerning health assessment and care.
Accurately reports and documents status, care rendered, and response to care.
CommUnityCare Health Centers is dedicated to providing accessible and comprehensive healthcare services to the community. They focus on patient needs in a community healthcare center setting.
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.
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.
Acts as primary point of contact for oncology pain patients after referral to the CPC, until the patient has sufficient knowledge and resources to direct self-care.
Responsible for monitoring, coordinating care, and educating cancer patients and families as they move through the CPC.
Responds to criteria-based referrals as soon as possible, no longer than 24 hours, and schedules with appropriate provider within 72 hours.
OHSU is Oregon's only public academic health center that cares for patients, leads groundbreaking research, and trains the next generation of health care professionals. As Portland's largest employer, they offer opportunities to learn and advance in a system of hospitals and clinics across Oregon and Southwest Washington.
Makes outbound calls to educate prospective patients and schedule provider visits.
Understands patient requirements and asks questions to gain trust and understanding.
Acts on opportunities to provide value to the patient through information about Strive Health programming.
Strive Health is dedicated to transforming the kidney care system through early identification, engagement, and coordinated care. They aim to improve outcomes for people with kidney disease, integrating with local providers and utilizing predictive data to support patients' care journey.
Facilitate collaboration with health plan care managers
Tuesday Health is a value-based palliative care provider group dedicated to transforming serious illness and end-of-life care. They deliver goal-centered care focused on alleviating physical symptoms and emotional stress for individuals and their caregivers.
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.
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.
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.