- Gather patient medical information between visits using electronic health record systems.
- Report monthly patient concerns, including falls, medication issues, behavioral concerns, and recent hospitalizations.
- Complete assigned principal care management interventions each month for approximately 15 patients per day.
- Report applicable issues to the ancillary program manager and/or Chief Clinical Officer.
- Provide additional employee training and shadowing support to newer employees.
- Track and monitor patient data and communicate across members of the medical team.
- Engage with patients and family members and report clinical summaries.
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