Conduct in home assessments including an evaluation of past medical history, review of systems, medication reconciliation, vital signs, and comprehensive physical exam Perform evidence based practice screenings including point of care testing (as appropriate) Identify diagnoses to be used in care management and active medical management in the furtherance of treatment For

Provide telephonic outreach to engage members discharged to home/community following an inpatient admission Conduct telephonic clinical case management with engaged members for the 30 day transition of care period. Services include conducting post discharge assessments, medication review and reconciliation, identification of gaps and barriers in discharge plans and SDoH n

Direct patient to proper exam/treatment area and prepare patient for examinations and other procedures. Assists in the transportation of patients and patient flow Obtain records and report vital signs and any other pertinent patient information to the RN or clinician Administer medication, perform various patient tests and instruct patients on procedural preparations unde

Works as a provider member within the HBMC interdisciplinary team in the direct delivery of home based medical care of a population within an assigned geography. Dedicated to improving the health and well being of patients, this position collaborates with the PCP, HBMC interdisciplinary teammates and consultants, and as needed, the health plan Medical Director and other h

Assess, plan, and implement care strategies that are individualized by patient and directed toward the most appropriate, lease restrictive level of care Utilize both company and community based resources to establish a safe and effective case management plan for members Collaborate with patient, family, and healthcare providers Identify and initiate referrals for social s

Assist in the review of medical records to highlight Star opportunities for the medical staff. Activities include data collection, data entry, quality monitoring, upload of images, and chart collection activities. Locate medical screening results/documentation to ensure quality measures are followed in the closure of gaps. Will not conduct any evaluation or interpretation

Communicates directly with patients and / or families either in person or on the phone to complete the registration process by collecting patient demographics, health information, and verifying insurance eligibility / benefits Responds to patient and caregivers' inquiries related to routine and sensitive topics always in a compassionate and respectful manner Organizes and

Conduct in home assessments including an evaluation of past medical history, review of systems, medication reconciliation, vital signs, and comprehensive physical exam Perform evidence based practice screenings including point of care testing (as appropriate) Identify diagnoses to be used in care management and active medical management in the furtherance of treatment For

Conduct in home assessments including an evaluation of past medical history, review of systems, medication reconciliation, vital signs, and comprehensive physical exam Perform evidence based practice screenings including point of care testing (as appropriate) Identify diagnoses to be used in care management and active medical management in the furtherance of treatment For

Conduct in home assessments including an evaluation of past medical history, review of systems, medication reconciliation, vital signs, and comprehensive physical exam Perform evidence based practice screenings including point of care testing (as appropriate) Identify diagnoses to be used in care management and active medical management in the furtherance of treatment For

Conduct in home assessments including an evaluation of past medical history, review of systems, medication reconciliation, vital signs, and comprehensive physical exam Perform evidence based practice screenings including point of care testing (as appropriate) Identify diagnoses to be used in care management and active medical management in the furtherance of treatment For

Supports patient care delivery in the areas of scheduling, insurance verification, and support services Ensure patients are fully ready to have successful interactions when they come in for a visit Own provider schedule accuracy, providing scheduling options, match patient needs to appointments across the continuum Adhere to multi disciplinary standardized scheduling prot

Supports patient care delivery in the areas of scheduling, insurance verification, and support services Ensure patients are fully ready to have successful interactions when they come in for a visit Own provider schedule accuracy, providing scheduling options, match patient needs to appointments across the continuum Adhere to multi disciplinary standardized scheduling prot

Manage chronic illnesses in a complex elderly population with multimorbid conditions focused on wellness, avoiding unnecessary hospitalizations and ER visits, providing patient education about disease processes, improving overall quality of care, and increasing patient satisfaction in the healthcare system Document timely with an added focus on closing HEDIS quality gap m

Conduct in home assessments including an evaluation of past medical history, review of systems, medication reconciliation, vital signs, and comprehensive physical exam Perform evidence based practice screenings including point of care testing (as appropriate) Identify diagnoses to be used in care management and active medical management in the furtherance of treatment For