- Serve as a patient advocate and navigator, guiding patients and caregivers through the healthcare system.
- Review provider notes, discharge summaries, and clinical documentation to provide personalized patient education.
- Complete emergency room and hospital follow-up calls, offering education on alternative access points.
- Perform comprehensive medication and allergy reconciliation with patients, caregivers, or facilities.
- Facilitate medication education and adherence support, including alignment with standing orders, protocols, and chronic disease management goals.
- Identify and support high-risk patients through proactive care coordination and outreach.
- Communicate clinical updates to Primary Care Providers (PCPs), ensuring timely follow-up appointments.
- Coordinate continuity of care across settings (e.g., inpatient, outpatient, specialty, post-acute), including referrals and collaboration with external providers and facilities.
- Collaborate with interdisciplinary care teams to identify barriers to care and improve care delivery.
- Actively participate in system-wide quality and population health initiatives.
- Monitor daily reports and EHR-based alerts to identify patients in need of outreach or follow-up.
- Maintain timely, complete, and compliant documentation of all patient interactions within the EHR.
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