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 collaborate with utilization management teams
* Approve or escal...