Responsibilities
- Ensure high quality care for patients by reviewing and researching concerns or complaints and recommending corrective action as appropriate.
- Identify and recommend solutions to issues and problems.
- Maintain excellent communication and effective working relationships with patients, office managers, providers and clinical team members
- Collaborate with assigned local teams to meet Maryland Primary Care Program (MDPCP AHEAD) performance metrics
- Collaborate effectively with integrated care team to support care coordination for patients
- Review patient non-compliance reports and conduct telephonic and/or in person outreach to ensure timely disease specific and wellness visits
- Provide Transitional Care Management including, but not limited to, post in-patient and/or emergency department discharge follow up
- Provide education and assistance as it relates to lifestyle coaching, dietary improvements and plans
- Provide education and assistance in accessing the necessary care outside of the Primary Care Office
- Collaborate with providers to review high-risk patients, develop a plan of care, and administer Care Plan to patients
- As needed, meet patients in the office or community for face-to-face visits
- Provide education and assistance with patient self-management goals
- Identify and coordinate referrals to community resources, home care, and disease management programs within Privia Preferred Network
- Operate independently within defined practice(s) and patient population to achieve agreed upon goals
- Attendance and participation in regular care team meetings to discuss patient care
- Perform other duties as assigned
Requirements
- Must be located in the DMV, MD Highly Preferred
- Travel: 25% Travel throughout our MD Market
Work Arrangement
Remote (City/Region) — MD Market
Additional Information
- 25% Travel throughout our MD Market
