You are responsible for supporting care delivery by partnering with Advanced Practice Providers to execute individualized care plans for patients with chronic kidney disease, hypertension, diabetes, and congestive heart failure.
This role focuses on enhancing clinical outcomes, patient engagement, and care coordination through education, remote monitoring, medication management, and longitudinal patient support.
Key responsibilities include visit preparation, care plan execution, disease management education, medication management, quality measure support, and cross-functional collaboration.
Collaborate with primary care providers to coordinate care for patients with multiple chronic conditions, ensuring high-quality care through telephonic and in-person outreach.
Conduct transitional care management including post-discharge follow-up and provide education on lifestyle coaching and dietary improvements.
Operate independently to achieve goals, attend regular care team meetings, and perform other duties as assigned.
Privia Health is a technology-driven national physician enablement company that collaborates with medical groups and health systems to optimize practices and improve patient care. The company is led by top industry talent and focuses on scalable operations and cloud-based technology to reduce healthcare costs and improve outcomes.
Manage patient physiological markers and provide clinical triage.
Conduct wellness calls and collaborate with care teams to set health goals.
Drive patient engagement and ensure adherence to RPM program standards.
Vivo Care is building a platform to make healthcare continuous, personal, and truly connected. It is a fast-growing startup with a culture of inclusion, collaboration, and innovation.
Responsible for using assessment and communication skills to engage patients in need of clinical support, determine priorities, and deliver patient-centered care.
Identify patient education needs through telephonic assessment and collaborate with healthcare teams to coordinate care and keep patients stable at home.
Serve as point of contact for patients, families, and providers, implementing interventions to improve health outcomes and reduce costs.
Vytalize Health is a value-based healthcare company that coordinates care for patients with chronic conditions, aiming to improve outcomes and lower costs. It is a rapidly growing organization with a startup culture, offering a dynamic environment.
Provide telephonic triage assessments and health education using nursing protocols and algorithms.
Utilize critical thinking and communication skills to manage diverse patient populations.
Work a flexible schedule that includes evenings and weekend shifts from your home office.
Carenet Health provides telephonic clinical assessments, health education, and utilization management services to patients and members. They are a growing organization with a collaborative national team of Registered Nurses, offering work-from-home options and a supportive culture.
Provide clinical assessment and nursing triage to diverse patients across the health continuum.
Assist in directing patients to the most appropriate level of care via telephonic health information.
Work in collaboration with Telehealth providers for virtual care visits and follow-up calls.
We bring hospitals and healers together in the pursuit of clinical effectiveness. With a portfolio of over 8 million patients, 7500 providers, and 400 healthcare facilities, we are a leader in clinical practice management with a culture of belonging and empowerment.
Review Home Health prior authorization requests for medical necessity using CMS regulations and Clover clinical guidelines.
Perform initial and concurrent clinical reviews, ensuring appropriate care in the least restrictive setting.
Collaborate with providers and internal teams to support timely decision-making and positive member outcomes.
Clover Health is a healthcare company that uses data and technology to provide affordable, high-quality insurance plans for seniors. The company fosters a remote-first culture with a diverse and mission-driven team focused on improving member outcomes.
Consult directly with patients and care teams to implement comprehensive pharmacy care management programs.
Optimize medication therapy regimens using principles of Comprehensive Medication Management (CMM).
Drive medication-related clinical quality initiatives, including GDMT optimization and adherence improvement.
Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic approach. The company provides interdisciplinary clinical resources and analytical tools to improve patient outcomes, and fosters a culture of innovation and compassion.
Supervise interdisciplinary team members including RNs, LVNs, and social workers to ensure high-quality care delivery.
Lead key initiatives to improve clinical care and launch new programs while resolving workflow issues.
Collaborate with providers to enhance patient care and support team performance reviews and onboarding.
Vynca provides comprehensive care for individuals with complex needs, aiming for more quality days at home. They are a close-knit community guided by core values of Excellence, Compassion, Curiosity, and Integrity.
Build trusting relationships with patients and providers to address health barriers and coordinate care.
Navigate medical, behavioral, and social systems to connect patients with appropriate resources.
Support value-based care outcomes through proactive outreach, documentation, and quality measures.
Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. As a growing and innovative organization, we operate with a high degree of agility.
Provide high-quality virtual primary care through video visits, including assessment, diagnosis, treatment, and patient education.
Manage a panel of patients, delivering comprehensive care across acute, chronic, and preventive needs.
Collaborate with the Care and Case Management team to develop care plans and support successful outcomes.
Included Health delivers integrated virtual care and navigation, aiming to raise the standard of healthcare for everyone. It is a growing company with a remote-first culture and a focus on breaking down barriers to provide high-quality care for every community.