Responsibilities
- Conducting in-depth telephonic assessments to understand each patient’s medical, psychosocial, and social needs.
- Reviewing and updating medical histories—including medications, chronic conditions, and preventive care.
- Developing individualized care plans and guiding patients through their treatment goals and care options.
- Providing empathetic, evidence-based education on chronic disease management and preventive health.
- Monitoring progress by phone, adjusting care plans, and ensuring patients stay connected to their providers.
- Completing Medicare Annual Wellness Visits (AWVs) via telehealth under physician supervision.
- Partnering with Healthguides who support non-clinical needs such as scheduling, transportation, food assistance, and SDOH resources.
- Performing proactive outreach and timely follow-ups to maintain continuity of care and patient engagement.
- Advocating for patients, helping them access the right resources at the right time.
- Documenting clearly and accurately in the EHR and care-management systems during and after calls.
- Supporting quality outcomes (HEDIS, NCQA) by coordinating preventive services and managing chronic conditions.
- Participating in virtual meetings, ongoing education, and clinical training to stay current with care standards.
- Using multiple communication methods (phone, text, patient portals, email, AI-supported tools) to reach high-risk patients.
- Collaborating in AI-driven outreach programs that help connect with vulnerable populations.
- Protecting patient privacy in a secure, private home workspace.
- Performing additional responsibilities as needed to support patients and the care team.
Work Arrangement
Hybrid
Additional Information
- Travel required: 10%-15% to clinical sites in the Atlanta, GA area.
- Work environment: Secure, private home workspace required to protect patient privacy.
