Join a mission-driven healthcare organization focused on improving patient outcomes and delivering coordinated, community-based care. This role plays a critical part in ensuring continuity of care and optimizing patient health through comprehensive care management.

Responsibilities:

• Develop, implement, and monitor individualized care plans in collaboration with patients, families, and healthcare providers


• Review and evaluate patient assessments and clinical data to identify risks and care needs


• Partner with primary care physicians to discuss and address patient care concerns


• Coordinate services across the continuum of care, including discharge planning


• Conduct routine patient monitoring and follow-ups to ensure quality care delivery


• Identify clinical issues requiring intervention to prevent hospitalizations or ED visits


• Facilitate utilization review processes and colla...