Coordinate and manage care for high-risk children and/or pregnant women to improve outcomes. Assess and respond to psychosocial, financial, functional, cognitive and medical needs. Identify and address gaps in patient care through proactive outreach and follow-up services. Identify and utilize patient’s systems of support and facilitators for reaching health goals. Monitor and respond appropriately to changes in patients’ condition, resources, or services. Serve as a liaison between primary care, specialty, and behavioral health services for coordinated patient treatment plans. Conduct comprehensive psychosocial needs assessments. Develop individualized care plans focusing on short and long-term medical and behavioral health treatment goals. Assist patients in navigating the healthcare system. Apply knowledge of community resources to address care gaps or improve quality of life conditions.
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Job Type
Full-time
Career Level
Mid Level