- 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 to reduce avoidable ED visits.
- Perform comprehensive medication and allergy reconciliation with patients, caregivers, or facilities.
- Identify and support high-risk patients through proactive care coordination and outreach.
- Communicate clinical updates to Primary Care Providers (PCPs).
- Coordinate continuity of care across settings, including referrals.
- Collaborate with interdisciplinary care teams to improve care delivery.
- Maintain compliant documentation of patient interactions, care coordination, and lab orders within the EHR.