- Perform telephonic outreach to enroll and engage patients.
- Develop and implement care plans in collaboration with Nurse Care Managers.
- Facilitate seamless transitions of care across care settings and dialysis centers.
- Conduct assessments to identify social determinants of health.
- Connect members to community resources such as housing and food security programs.
- Provide patient advocacy by identifying and addressing barriers to care.
- Maintain documentation of patient interactions and care plans.
- Educate and empower patients to manage their conditions.