**Req Number** 185113

Job Description

Coordinates and participates in activities related to Care Management services to family members and caregivers.

Job Responsibility

+ Utilizes patient-centered motivational interviewing techniques to build rapport and help patients improve their health.
+ Supports the primary care team by providing panel management to decrease the number of patients lost to care, non-compliant in follow up care or disconnected from primary care. Participates in the development, maintenance, and adjustment of individualized care plans for high-risk patients that address both medical and social barriers to accessing care.
+ Acts as a professional liaison between hospitals, primary care providers, specialists, and community resources on behalf of patients to ensure patient-centered care coordination.
+ Identifies and tracks special populations, including high-risk patients and other populations due for preventive or chroni...