Actively engages a population of medically vulnerable or chronically ill patients in their care, assisting them through the process of working towards better health by providing support, encouragement, and education. Communicates with patients (and caregivers) in person, in groups, by telephone and via electronic means. Monitors patient-reported biometrics, medication adherence, reported challenges/barriers and promptly connects the patient with the appropriate resources, and/or notifies the patient's care team for additional follow-up. Advocates and facilitates referrals to gain access to services and resources for patients/teammates, including assistance programs, community based services and mental health support. Assists providers' offices with member specific missed appointments through outreach and scheduling. Provides customized, evidence-based patient education in a variety of areas including but not limited to weight management/exercise, tobacco cessation, stress reduction and chronic disease self-management. Advocates for help for those who frequently access inappropriate levels of care (e.g., visiting the emergency department for conditions that can be better treated by a primary care physician).
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Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED