- Manage overall care management of an assigned patient panel using clinical expertise and value-based care principles.
- Build trusting relationships with patients and families to provide clinical and emotional support.
- Serve as a patient advocate and community liaison to ensure timely access to resources and treatment plan adherence.
- Conduct comprehensive assessments to identify patient/caregiver needs, social determinants of health, goals, and preferences.
- Develop and maintain patient-centered care plans based on ongoing evaluations.
- Coordinate post-discharge follow-up, medication reconciliation, referrals, and care plan implementation across providers.
- Coordinate interdisciplinary care to support seamless transitions across care settings.
- Monitor care plan effectiveness and modify interventions as needed to achieve outcomes.
- Educate patients and caregivers on treatment options, self-management strategies, and available resources.
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