Care Management Coordinator - VIVO Health

Job description

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 chronic care services. - Identifies and tracks patients discharged from the inpatient service or the emergency department. - Uses team-based communication strategies to close the loop on referrals, hospital follow-ups and any outstanding items identified in the patient's c...