Responsibilities
- Lead illness management for individuals with serious, high-acuity conditions by implementing personalized care strategies and adjusting treatment plans as medication or clinical needs change.
- Serve as the primary point of contact between patients and healthcare providers, facilitating care coordination, appointment scheduling, and follow-up after hospital discharge.
- Evaluate patients' social and cultural backgrounds through individualized assessments to uncover unmet needs like food insecurity or unstable housing, and create targeted interventions.
- Guide patients and caregivers through local healthcare systems in New Mexico, equipping them with skills to communicate effectively with specialists and access telehealth or transportation services.
- Support digital communication processes by maintaining templates, troubleshooting technology issues, and accurately updating patient records in the Case Management System (CMS).
- Connect patients with community resources such as legal assistance and food programs, while building relationships with local New Mexico organizations to expand service access.
- Offer psychosocial support using motivational techniques to strengthen patient resilience, improve adherence to treatment, and provide emotional support to families.
- Keep thorough, accurate records of all patient interactions, including time spent and actions taken, ensuring compliance with Medicare requirements for clinical and social service documentation.
Work Arrangement
Remote
Team
Independent role with minimal oversight
Not specified
