Deliver care coordination services for patients enrolled in Chronic Care Management (CCM), Principal Care Management (PCM), and Remote Patient Monitoring (RPM) programs.
Conduct telephonic assessments and develop personalized care plans based on patients’ specific needs and health goals.
Track patients’ health progress, monitor adherence to care plans, and assess progress towards desired health outcomes.
Maintain regular communication with patients, their caregivers, and primary care providers to ensure effective care.
Provide education to patients on managing chronic conditions, understanding medications, and adopting preventive and self-management strategies.
Identify and address any obstacles or gaps in care that may impact patients’ health and quality of life.
Collaborate with a multidisciplinary care team, including nurse practitioners, pharmacists, social workers, and community resources, to optimize patient care.
Document all care coordination efforts and interventions accurately in the electronic health record (EHR) system.
Ensure compliance with relevant policies, regulations, and standards of care.
