Job Abstract

Collaborates with care team members to reach population health management goals of improving patient access to care, reducing number of emergency visits,and decreasing readmissions. Telephonic outreach to patients discharged from the hospital or emergency room to schedule follow up appointments and review medications and treatment plans. Make referrals to members of the extended care team and/or notify provider of post discharge needs or discrepancies in plans of care. Participate in population ... more details

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