Assists physicians and other healthcare providers in identification of patients in their panel that need aggressive disease management. Supports primary care and sub-specialty co-management with timely communication, follow-up and integration of the patient's disease management plan. Assists medical director to measure patient outcomes. Works with providers to redesign care processes and improve quality. Involved in patient education related to specific chronic diseases. Works with providers to develop and implement patient education sessions. Facilitates patient access to care based upon the needs of the patient and family. Works with the electronic medical record team members to develop and manage disease specific registries. Performs other duties as assigned or requested.
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