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.
Provide day-to-day administrative and clinical support to assigned medical provider(s).
Coordinate patient care for a geriatric and Medicare population receiving mobile medical services.
Support Chronic Care Management (CCM) activities and ongoing panel management.
They provide dedicated support to mobile geriatric medical providers serving Medicare patients in the field. The company seems to have a collaborative, mission-driven healthcare environment.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Own high-volume inbound patient and provider communication queues.
Serve as the first point of contact for patients, resolving inquiries in real time.
Act as a reliable liaison between patients and their care teams.
Oshi Health is revolutionizing GI care with a digital clinic model, providing convenient access to an integrated and multidisciplinary care team. They are dedicated to creating a workplace that prioritizes their team and fosters inclusivity, reflected in their "Best Place to Work" awards.
Conduct high-volume outbound and inbound calls with patients, providers, and pharmacies.
Collaborate with patients to identify and remove barriers to medication adherence.
Accurately document all interactions, outcomes, and identified barriers in appropriate systems.
Aledade empowers independent primary care practices. They were founded in 2014 and have become the largest network of independent primary care in the country, with a collaborative, inclusive, and remote-first culture.
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.
Actively support the continuity journey for patients enrolled in our internal PAP treatment program.
Contribute directly to the stability and growth of our recurring revenue model by keeping patients engaged in therapy through timely outreach and proactive retention efforts.
Coordinate follow-up, execution, and documentation to ensure a smooth and reliable experience for patients.
Dreem Health is America’s leading digital sleep clinic, powered by Sunrise’s technology. They make sleep care simple by offering home-based testing, expert telehealth visits, and personalized treatment plans. The company consists of 100+ clinicians, engineers and operators across the U.S. and Europe.
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.
Engage and enroll eligible health plan members in supportive care services.
Educate members on Tuesday Health’s service offerings and support ongoing engagement.
Provide ongoing telephonic customer service to members and their caregivers.
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 and are shaping the future of community-based palliative care nationwide.
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.
Follow VitalCaring billing Standard Operating Procedures and regulatory billing guidelines
Collaborate with your supervisor and the billing team to address payor and billing concerns
Ensure documentation accuracy and submit claims in accordance with Medicare and other payor requirements
VitalCaring is a leading provider of home health and hospice services. Founded in 2021, VitalCaring has grown into a leading provider of home health and hospice services, with over 65 locations across the country. They foster a culture of support, growth, and excellence.