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 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.
Assess, plan, coordinate, and monitor patient care.
Develop, implement, and monitor individualized care plans.
Coordinate care across providers, facilities, and community resources.
Limitlessli specializes in recruiting, hiring, and managing high-caliber remote staff for dynamic and growing healthcare facilities. They connect clients with highly qualified professionals, offering tailored services to meet unique business needs, leveraging an extensive global network.
Assesses symptoms via telephone to identify acuity and appropriately disposition caller/patient using best-practice updated protocols.
Documents call criteria in eMR within a timely manner, promoting second-level triage and virtual care visits when appropriate.
Provides health information to customers via UnityPoint Health’s approved resources, maintaining strict confidentiality.
UnityPoint Health is committed to its team members and has been recognized as a Top 150 Place to Work in Healthcare by Becker's Healthcare. With a collective goal to champion a culture of belonging where everyone feels valued and respected, they honor the ways people are unique and embrace what brings us together.
Coordinate and implement medical case management to facilitate case closure.
Assess appropriate utilization of medical treatment and services.
Review medical records and assess data to ensure appropriate case management process.
Berkley Medical Management Solutions (BMMS) provides managed-care service for W.R. Berkley Corporation, focusing on injured worker’s return to work. BMMS was started in 2014 and combines clinical practices, return-to-work strategies, and software for workers’ compensation cases.
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!
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.
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.
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.
Perform thorough preoperative nursing assessments, including medical history review and allergy verification.
Provide clear patient education regarding preoperative instructions and NPO guidelines.
Communicate effectively with surgeons offices and anesthesia teams.
Brigham and Women's Faulkner Hospital is a non-profit, community teaching hospital that offers comprehensive care in a wide variety of specialties. They are a designated Magnet hospital that believes everyone should have the chance to live a healthy life.