**Description**

Job Summary:
Proactive patient outreach and care coordination for a panel of patients to achieve optimal outcomes and wellness, while decreasing preventable ED, inpatient and readmission visits. Functions as a clinical liaison, facilitator, advocate and collaborator in a multidisciplinary care team across the continuum of care to provide complex disease management interventions to high risk and post discharged patients identified. Facilitates transformational care delivery in clinical settings and advance the mission and goals of population management activities.

Primary duties and responsibilities:
Patient Assessment and Goal Setting:
1. Utilizing assessment skills and risk assessment tools to collect subjective and objective information pertaining to the health status of the patient and identify barriers that will require a team-based approach.
2. Utilize a team-based, holistic, patient-centered, evidence based approach to identify patien...