Provide care coordination services to patients enrolled in chronic care management (CCM), principal care management (PCM), and remote patient monitoring (RPM) programs.
Conduct telephonic assessments and develop care plans based on the patients' needs and goals.
Monitor the patients' health status, adherence to care plans, and progress towards desired outcomes.
Communicate with the patients, their caregivers, and their primary care providers regularly and effectively.
Educate the patients about their chronic conditions, medications, preventive measures, and self-management skills.
Identify and address any barriers or gaps in care that may affect the patients' quality of life or health outcomes.
Collaborate with other members of the care team, such as nurse practitioners, pharmacists, social workers, and community resources, to coordinate and optimize the patients' care.
Document all care coordination activities and interventions in the electronic health reco...