- Execute person-centered care plans for patients with serious, high-risk illnesses and assist with monitoring and revising disease-specific plans.
- Coordinate care between patients and billing practitioners, including provider availability, rescheduling, and post-hospital discharge support.
- Conduct person-centered assessments to identify social needs affecting the management of serious conditions.
- Develop action plans to address unmet needs such as food insecurity and housing instability.
- Help patients and caregivers navigate healthcare services, communicate with specialists, and coordinate transportation or telehealth access.
- Refer patients to supportive services and community-based resources, and maintain partnerships with local organizations.
- Use motivational interviewing and tailored education to support chronic illness management and treatment adherence.
- Coordinate technical workflows, troubleshoot issues, and update patient charts in the Case Management System.
- Maintain detailed interaction logs and documentation that meet Medicare clinical and social integration service standards.