Care Navigator Resume Sample

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Shayne Donnelly
92852 Stamm Locks,  Chicago,  IL
+1 (555) 653 4749

Work Experience


Care Navigator
07/2016 - PRESENT
Boston, MA
  • Documents in a manner that is concise and relevant to the patient’s condition and plan of care
  • Facilitates referral of patients to appropriate resources to meet their health and financial needs
  • Documentation in medical record(s) all relevant information to the social worker’s assessment, the patient’s plan of care and direct assistance in a concise manner
  • Assess needs of all teams. Supports care management’s teams and its patients. Attends visits with patients/families as required
  • Attend continuing education conference as deemed necessary
  • Displays nonjudgmental acceptance, maintains confidentiality and establishes a positive rapport and working relationships with patients/family/visitors/staff/community
  • Coordinates patient care with CHP Nurse Manager and CMO. Requests extra support from RN Care Coordinator or Level II navigators when patients require higher levels of intervention
  • Provides social support through home visits and telephonic follow-up
Patient Care Navigator RN
07/2010 - 04/2016
Chicago, IL
  • Demonstrates strong communication skills with patients, families, medical staff, colleagues and other departments throughout the continuum of care
  • Provides basic education to patients and families about chronic disease management and leads them to create self-management goals
  • Initiate discharge phone calls to identified patient population to ensure smooth transition of care and adoption of identified treatment plan
  • Plan interventions appropriate to patients’ medical and nursing diagnoses, age, abilities and resources; establishes and implements learning and disease self-management plan for patient/significant others; documents planning process according to organizational standards
  • Provide teaching to patients/families related to patient’s diagnosis, pathology, medical and nursing treatment plans, discharge needs and health goals; documents each element of care per organizational and unit standards
  • Review culture follow-up Epic work queue and collaborates with pharmacist, and/or emergency department provider, to ensure appropriate treatment plan; engages with patient to notify of any change in treatment plan, and facilitate appropriate follow-up with community provider
  • Collaborate and communicate care with patient’s PCP and/or community provider
  • Maintain high ethical standards in practice
  • Advocate for the patient and family and protects patient’s autonomy, dignity and decision making rights
Population Health Post-acute Care Navigator
03/2006 - 06/2010
Phoenix, AZ
  • Maintain confidentiality of all patient information and holds others accountable for maintaining confidentiality
  • Deliver sensitivity to cultural diversities of patients and coworkers
  • Evaluation and assessment for identified needs and barriers in preventing readmissions. (100%)
  • Displays nonjudgmental acceptance, maintains confidentiality, and establishes a positive rapport and working relationship with patients/family/visitors/staff/peers/community. (100%)
  • Assists patients with applying for and receiving prescription assistance through various available programs. 50%
  • Maintains harmonious relationships with all community clinics, CMG clinics and hospital staff, providing support and displaying a positive attitude to ensure quality patient care. Communicates patient needs appropriately and effectively to other health care providers. 100%
  • Develops and maintains relationships within the community in order to provide a variety of cost-reduced services for patients in need. 40%
  • Participates in patient care conferences, such Contract/DSRIP/Clinic meetings, to better identify and address patient needs. 20%
  • Documentation in medical record(s) all relevant information to the social worker’s assessment, the patient’s plan of care and direct assistance in a concise manner. 50%

Education


Eastern Washington University - Riverpoint Campus
2001 - 2006
Bachelor's Degree in Social Work

Professional Skills


  • Strong verbal/written communication and organizational skills to effectively communicate with patients and matrix partners
  • 2 Has strong conflict management and negotiating skills
  • Strong communication, customer service, interpersonal skills
  • Strong computer skills, particularly related to Microsoft applications Word, Access, Visio, Excel, PowerPoint and Outlook
  • HS Diploma and prior experience working in Case Management with HIV and LGBT populations
  • Above average written and verbal skills including organizational abilities
  • Experience in health promotion at a community level and past experience engaging diverse populations is highly desired

How to write Care Navigator Resume

Care Navigator role is responsible for clinical, organizational, computer, oncology, training, refining, design, education, research, insurance.
To write great resume for care navigator job, your resume must include:

  • Your contact information
  • Work experience
  • Education
  • Skill listing

Contact Information For Care Navigator Resume

The section contact information is important in your care navigator resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:

  • First and last name
  • Email
  • Telephone number

Work Experience in Your Care Navigator Resume

The section work experience is an essential part of your care navigator resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous care navigator responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular care navigator position you're applying to. The work experience section should be the detailed summary of your latest 3 or 4 positions.

Representative Care Navigator resume experience can include:

  • Effectively communicates problems, concerns or issues to the Supervisor and/or Manager appropriately and promptly
  • Two years prior healthcare/insurance experience
  • Demonstrated ability to work well with people of various ages, backgrounds, ethnicities, and life experiences
  • Proficient computer skills – report generation, data entry
  • Customer service abilities, including effective listening
  • Strong computer competency, including knowledge of Electronic Medical Records, Computerized Appointment/Billing Programs and other Microsoft Office Programs

Education on a Care Navigator Resume

Make sure to make education a priority on your care navigator resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your care navigator experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.

Additional details to include:

  • School you graduated from
  • Major/ minor
  • Year of graduation
  • Location of school

These are the four additional pieces of information you should mention when listing your education on your resume.

Professional Skills in Care Navigator Resume

When listing skills on your care navigator resume, remember always to be honest about your level of ability. Include the Skills section after experience.

Present the most important skills in your resume, there's a list of typical care navigator skills:

  • 1 Has good verbal and written communication skills
  • Writing — communicating effectively in writing as appropriate for the needs of the patient
  • Access to reliable vehicle, valid driver's license, good driving record and proof of automobile insurance required
  • PC Skills (Windows, Excel, and Word)
  • Prior experience with patient home visits
  • Prior experience in the health care field

List of Typical Experience For a Care Navigator Resume

1

Experience For Patient Care Navigator Resume

  • Demonstrates appropriate and timely use of the EMR
  • Strong medical terminology knowledge
  • Work with clinic intervention specialists to maximize participant’s experience
  • Developing and maintaining Physician relationships
  • Working as a patient advocate
  • Facilitate partipants’ use of computer technology including wearable activity tracking devices and computer-based training
2

Experience For Patient Care Navigator RN Resume

  • Regular Presentations, including to a panel of physician specialists
  • Assess needs of all teams. Supports care management’s teams and its patients. Attends visits with patients/families as required. 30%
  • Support and participate in community outreach/benefit programs and committees. 15%
  • Adheres to the regulatory requirements for social work intervention/oversight based on state and federal guidelines (i.e.: ESRD, transplant and rehabilitation patients)
  • Maintains current knowledge and researches availability of community agencies/resources for social, emotional or financial assistance. Understands placement intricacies and can interpret requirements from state, local, and federal agencies to optimize placement of patients in the most appropriate setting based on patient’s needs
  • Serves as a consultant for processing issues such as guardianship, abuse/neglect, power of attorney, healthcare surrogate, advanced directives, and psychiatric involuntary admission. Initiates/completes forms required for post-acute placement
  • As patient is transferred, communicates pertinent information to next Social Worker and Care Manager to transition the patient to the next level of care. Documents activities with entries that are consistent with meeting department/facility requirements, licensure and regulatory guidelines
  • Supports interdisciplinary team conferences and contribute to the planning and review of care for patients presented as needed
  • Works collaboratively with both internal and external entities to facilitate seamless transitions across the continuum of care by adhering to departmental administrative TOC workflow standards
3

Experience For Customer Care Navigator Resume

  • At time of patient discharge, initiates and completes the TOC process on behalf of client's providers and ensures a seamless handoff of information to RN Care Managers and other interdisciplinary team members for further follow-up post discharge
  • Collects, tracks, trends and reports clinical data, as needed, for all Transitions of Care Program patients, Low Risk Care Management patients, Social Support Program patients, patients discharged from ED, and patients requiring outreach for closing care gaps
  • Maintains information flow and communications with non-SMG collaborating providers to ensure efficient patient care
  • Attends all pertinent departmental meetings and trainings that involve Care Management team, Social Support Program, hospitalist or extensivist workflows
  • Assists with special projects as assigned and completes them within the required timelines
  • Knowledge of the location of services provided by the hospitals and clinics (or ability to quickly become familiar) to be able to assist guests with directions and/or transport; the local geography
  • Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certification
  • Current driver’s license and proof of insurance, and access to dependable vehicle
  • Evaluation and assessment of patient for identified needs to include education and
4

Experience For Population Health Post-acute Care Navigator Resume

  • Acceptance and response to referrals from the multi-disciplinary health care team and
  • Work with study participants to engage and encourage participants to continue their intervention activites
  • Assumes responsibility for professional growth and development of self, utilizing professional organizations, workshops, seminars, and other self-directed learning activities as applicable
  • Patient Care Protocol development
  • Community education and outreach
  • Uses standardized assessment tools to monitor patient distress levels every other week - reports issues to the care team and supportive services as necessary using referral algorithms designed by SHC clinical teams
  • Coordinates data, community services and AHN resources into a seamless model of access and care benefiting patients, physicians and family members
  • Provides patient with welcoming/hospitality packet to include information related to supportive services and programs that are available
5

Experience For Breast Patient Care Navigator RN Resume

  • Teaches patients how to use My Health for communication and access to information
  • Assesses willingness/interest in clinical trials
  • Provides access to patient-specific educational materials suited for their education level point in treatment and current needs
  • Provides resource information available in the community and at Stanford whichare specific to patient's needs (Path Well, Cancer Supportive Services, financial counseling, nutrition, spiritual services, Social Work, etc.)
  • Links patients interested in connecting with other patients with similar disease types to patient-to-patient program
  • Serves as contact primary point of careto direct the patient to the appropriate source - Who? What? Where? Why? When?
  • Identify and address language barriers and health literacy issues with patients
  • Manage assigned patient referred by clinical team
  • Document patient encounter/ in EPIC
6

Experience For Medicaid & Charitable Care Navigator Resume

  • Responsible for community outreach and high risk populations to connect the patient to appropriate clinical care
  • Works with CM/RN/SW to facilitate the patient's transfer of care
  • Integrates and facilitates care for patients across care continuum
  • Identifies the patient's insurance concerns and issues and facilitates resolution
  • Works as a liaison between the hospital and post-acute providers
7

Experience For Lbsw-pediatric Care Navigator Resume

  • Provides support to the patient's family members and caregivers. Identifies problems and opportunities and takes appropriate action
  • Use case management processes to ensure quality care is delivered to the Practice’s patients, families and caregivers in the most efficient and effective manner across the care continuum
  • Document each patient’s individualized care plan and care coordination in the Practice’s database
  • Coordinate the patient’s care by facilitating patient, family or caregiver access to medical home providers, employees and resources as needed by the patient
  • Develop and maintain relationships among patients, families and caregivers, and the patient’s care team
8

Experience For RN, Ambulatory Care Navigator Resume

  • 6 Contact patient and/or follow up on all additional follow up orders per provider
  • 8 Appropriate education to patients on changes to discharge plan
  • Works closely with multidisciplinary team to develop and implement the patient's plan of care
  • Ensures open communication with providers, patients, and caregivers to coordinate services within the organization, at outside facilities, at home and physician offices in the community to promote care and maximize care coordination and patient satisfaction
  • Follow up with patients throughout the hospital stay. Continue to manage patient post-discharge for a period of 90 days facilitating patient self-management to avoid a preventable return to hospital
  • Manage patients discharged from hospital to ensure the patient has an appointment with his/her provider and review any unmet needs prior to the upcoming appointment
9

Experience For Oncology Care Navigator Resume

  • Oversees hand-off of patients to post-acute facility, agency and principal acute provider and maintains contact (either phone or in-person) for 90 day episode and providing interventions when needed
  • Plan and conduct telephone consultations with members to assess and monitor needs, care plan, review effectiveness of services and support self-management
  • Assist patients in processing payment requirement
  • Provide outreach, education and other clinically based activities to patients and caregivers through the use of home and/or telephonic visits to help them make informed decision regarding self-care
  • Collects data on patient outcomes and provides monthly and quarterly reports
10

Experience For RN Care Navigator Resume

  • Work with physician to facilitate, coordinate and ensure patient access to timely care
  • Central point of contact for navigated patients; including interaction with medical, nursing, ancillary services, and when appropriate the clinical research coordinator
  • Provides education to patients, families, and significant others; acts as an information resource to health care professionals, patients, and the public
  • Collect and report data from patient on barriers to health care etc
  • Track and monitor navigated patient compliance with patient treatment plan
  • Assist patients with referrals to outside resources and care coordination as needed

List of Typical Skills For a Care Navigator Resume

1

Skills For Patient Care Navigator Resume

  • Experience managing complex patients in an acute care setting with a focus on reducing readmission
  • Experience managing complex patients in an Emergency Department setting
  • At least five years' experience in nursing at least two in oncology (inpatient and outpatient setting)
  • Triages all incoming referrals/authorizations in order of priority for processing. Enters information into MSR computer and other required/applicable systems
  • Direct experience involving Insurance Verification, Pre-authorizations and other Patient Access functions
  • Experience coordinating Referral Authorizations
  • Strong understanding of case management and/or outreach services
  • Two to five years’ work experience in an RN role in the acute care hospital setting
2

Skills For Patient Care Navigator RN Resume

  • Two to five years’ work experience in an RN role in the Emergency Department setting
  • Experience working with customers in medical or managed care environment required
  • Demonstrates a commitment to the organization through ongoing participation in team- based meetings
  • Serves as a resource and maintains positive and effective relations with nursing, medical staff, and other organizations/customers
  • Experience in medical/social services and/ or entitlements work
  • Experience in public contact position
3

Skills For Customer Care Navigator Resume

  • Active and unrestricted certification as a Board Certified Behavior Analyst, with experience in behavioral health
  • Registered Nurse with 2-3 years experience in Cancer Care and Treatment required
  • Clinical experience in physician office practice or hospital
  • Three years of hospital experience
  • Clinical healthcare experience in an outpatient medical practice
4

Skills For Population Health Post-acute Care Navigator Resume

  • Clerical experience in an office setting or hospital registration or department secretary
  • Possesses optimistic warmth and empathy for the customers’ experience
  • Leads process improvement strategies within the patient's experience to improve flow and operations
  • Work with physicians and social services to obtain insurance prior authorizations for medications as needed
  • Working knowledge of health information technology
  • Managing outpatient mental health cases throughout the entire treatment plan
5

Skills For Breast Patient Care Navigator RN Resume

  • Coordinating patient care and physician communication across multiple specialties
  • Provides counseling and crisis intervention for promoting patient and family understanding
  • Basic understanding of ALOS, re-admission reasoning and rates, Gaps in Care, health insurance, and other concepts as needed, guiding by local care scenarios
  • Comfort with exploring and learning to use new or unfamiliar applications or databases
  • Streamline appointments and paperwork by helping patients with scheduling appointments and preparation
  • Establish appropriate mechanisms to ensure service continuity during both planned and unplanned absence and undertake succession planning
  • Provides proactive contact and support improving the coordination of care,making connections to the clinical care team as needed
  • Performs assessments and triage of patient care needs for new and ongoing patients, including patients on a clinical research study
  • Helps oversees the planning, scheduling, and implementation of care for navigated patients
6

Skills For Medicaid & Charitable Care Navigator Resume

  • Assist individuals, family members, and caregivers through assessment, care coordination, problem-solving, education, planning, referral and follow-up
  • Assist the Community Support Manager in coordinating and facilitating support group activities
  • Provide support to the chapter in promoting and recruitment for the fundraising and conference events in the community
  • Works collaboratively with the rest of the Hospitalist team, including regularly communicating feedback from patients and providers
  • Work with home health and hospice staff to collect data, track outcomes, and support strategic planning processes
7

Skills For Lbsw-pediatric Care Navigator Resume

  • Adheres to and participates in Company’s mandatory training which include but are not limited to HIPAA privacy program/practices, Business Ethics and Compliance programs/practices, and Company policies and procedures
  • Year of direct experience involving insurance verification, pre-authorizations and other patient access functions
  • Experience Working with Autism children / adolescents
  • Provide education regarding Home Health and Hospice services
  • Computer literacy in a Windows environment, including MS Word
  • Education in field of nursing, medicine, psychology, social work
  • The physical requirements and working conditions in which the job is typically performed are available I Occupational Health Department
  • Registered Nursing License required from the State of Ohio
8

Skills For RN, Ambulatory Care Navigator Resume

  • Current RN license from Texas Board of Nursing
  • Complete training in patient navigation
  • Document ongoing status, interventions, patient response and outcomes in accurate, timely manner
  • Takes action to achieve goals identified during the evaluation process
  • 3 Has the ability to collaborate with physicians, nursing management, and other staff
  • Collaborates with medical providers, patient care staff and clinic management in the planning and implementation of patient and staff education
  • Ensure the member has an understanding of the treatment process
  • Provide educational information as appropriate regarding the member diagnosis
9

Skills For Oncology Care Navigator Resume

  • Act as a liaison and point of contact between the family, Beacon, and treating facility
  • Work with Quality Director to implement comprehensive advanced care planning for a targeted subpopulation
  • Monitor performance of individual health educators or coaches and recommend training or other improvement plans
  • Provide a designated number of the (4) weeks series “Early Stage Memory Loss: Staying Connected”
  • Promote a culture of collaboration and coordination between Home Health and Hospice
  • Use predictive analytic tools to improve quality of patient care. This includes: Data entry and management in the predictive analytics program and Utilization of dashboards and reports for process improvement
  • Direct experience involving Insurance Verification, Pre-Authorizations, and other Patient Access functions
10

Skills For RN Care Navigator Resume

  • Adhere to specific branch, area, or regional-specific performance and/or productivitiy benchmarks
  • Familiarity with LGBT, HIV and health-related issues and community resources
  • See independent projects through to completion
  • Provides education to patients about chronic disease management and leads them to create
  • Actively participates in both departmental and hospital-wide process improvement efforts
  • Plans and implements through multi-disciplinary means, strategies to reduce length of stay, and over/inappropriate consumption of resources
  • Recognizes unsafe acts or conditions as defined by Kingwood Medical Center policies and procedures, and takes immediate action to correct
  • Provides services to patients at risk for hospital readmissions and emergency room

List of Typical Responsibilities For a Care Navigator Resume

1

Responsibilities For Patient Care Navigator Resume

  • Follows established departmental policies, procedures, and objectives, continuous quality improvement objectives and safety, environmental, and/or infection control standards
  • Social Perceptiveness —being aware of others’ reactions and understanding why they react as they do
  • Assists patients in understanding care plans and instructions and helps patients actualize health management plans and goals
  • Provide Nursing support when and as needed for Interventional Breast Studies
  • Make appropriate recommendations for changes to the current program both locally and at a corporate level, and assist in delivering program improvement
  • Stay current on the latest oncology nursing developments and participate in conferences
  • Travel during the day to local provider locations up to 4 days weekly
2

Responsibilities For Patient Care Navigator RN Resume

  • Coordination — adjusting actions in relation to others’ actions
  • Maintain a case load of patients requiring care navigation support and document as appropriate
  • Assist in the development, implementation and monitoring of corporate and/or HealthONE policies and procedures as they relate to VBC programs
  • Develop working relationship with supported primary care practices
  • Managed Care Understanding specifically ACO/Value Based Contracts
  • Coordinates authorizations with PCCs and/or Case Managers according to established HMHS contract standards and guidelines to include timely data entry
3

Responsibilities For Customer Care Navigator Resume

  • Designs or participates in the creation of health education materials
  • Work collaboratively with care providers to coordinate and plan the access to care for patients across the ARH continuum
  • Work with nursing and care managers to identify ARH service opportunities (retail pharmacy, home care services, home health services, etc.) to patients being discharged
  • Make follow-up contacts to high-volume patients for local and system services
  • Provide a local resource to transition follow-up services (for example, prescription refills) through the system services (for example, the prescription mail order program)
  • Promote and coordinate with home care services for post-discharge durable medical equipment and home health orders
  • Deliver completed prescriptions and supplies to patients or their caregivers
  • Assist in the completion of paperwork for medication access programs
  • Contact other resources for patient information to potentiate ARH services
4

Responsibilities For Population Health Post-acute Care Navigator Resume

  • Coordinate with local service line directors to provide contiguous and coordinated services post-discharge
  • Performs direct entry and maintenance of patient application(s) for services
  • Responds to and provides additional information and or appeals as required by pharmaceutical companies
  • Maintains records and statistics for the purpose of evaluation and program analysis
  • Sustains general knowledge of manufacturer indigent patient program criteria and communicates changes and developments
  • Investigates and analyzes critical operational situations and provides directions for the resolution of problems
5

Responsibilities For Breast Patient Care Navigator RN Resume

  • Responsible for community outreach and high risk populations to connect the patient to appropriate clinical care. Coordinates data, community services and AHN resources into a seamless model of access and care benefiting patients, physicians and family members
  • As part of the Emergency Department team, the Patient Navigator assists patients, family members or care givers in understanding care plans and instructions and helps all parties actualize health management plans and goals
  • Receive patient requests for assistance and refers patient to appropriate member of Provider team for resolution, unless Navigator can resolve on his/her own and within the scope of the position
  • Works collaboratively with the rest of the Emergency Department team, including regularly communicating feedback from patients and providers
  • Fully discloses relevant training, experience and credentials, in order to help patients understand the scope of services the Patient Care Navigator is qualified to provide and refrains from any activity that could be construed as clinical in nature
6

Responsibilities For Medicaid & Charitable Care Navigator Resume

  • Assist with decision points in choosing a provider
  • Schedules physician follow-up appointments for patients discharged from ED/inpatient
  • Coordinates appointments for ER/inpatient patients who do not have a documented primary care physician
  • Coordinates appointments with Specialist if the ER/inpatient physician dictates that follow-up is prescribed
  • Contributes to the day-to-day processes of the ER unit/inpatient unit
  • Help the member understand their condition and health risks as well as best practice care
  • Arrange access to face-to-face clinical assessment to determine the most appropriate treatment options
7

Responsibilities For Lbsw-pediatric Care Navigator Resume

  • Identify and refer the member to providers in their community to address the treatment needs
  • Support continued member engagement in treatment
  • Advocate for any ancillary services which would support the member recovery process
  • Manages caseload of patients referred to them by the PCP within the office by maintaining a care plan in a workable/amendable care plan (longitudinal care management) with the patient and family
  • Manages an Episodic Care Management caseload of patients referred to them by the PP
8

Responsibilities For RN, Ambulatory Care Navigator Resume

  • Daily responsibilities include: contact patients seen in the ED or discharged from an inpatient site to ensure follow up appointment has been made and work with the Clinic Case Manager to facilitate removing any barriers to getting prescribed follow up care
  • Weekly has responsibilities to work through the CIN/ACO team to contact patients determined to be at high risk for readmit and/or high cost based on access to patients attributed to that clinic
  • Monthly has responsibilities to work through the CIN/ACO team to determine patients in need of 90 day prescription needs
  • Maintain two step risk stratification and empanelment requirement for CPC+
  • Educate staff on monthly quality focus as determined by the Physician Quality Advisory Board along with the Quality Directors
  • Facilitate comprehensive medication management with PCP, patient, and pharmacist
  • Run report on MAWV and set goals for clinic to meet 85% year end goal
9

Responsibilities For Oncology Care Navigator Resume

  • Run report to determine continuity of care per CPC+ requirement
  • Work alongside Clinic Case Manager to overcome barriers to care
  • Conduct PFAC each quarter, report findings to appropriate team members, implement change based on findings with Quality Director
  • Work with Quality Director to determine eCQM focus and goals for site
  • Maintain collaborative care agreements with specialists
  • Meet at least weekly with Director and clinic staff to review quality goals
  • Meet monthly with entire Population Health quality team to discuss goals and opportunities
10

Responsibilities For RN Care Navigator Resume

  • Mails, collects, scans and telephonically assists customers to complete health risk assessments for both CSNP and Medicare Advantage Plan customers. Provides support to PHM program staff in all non-clinical HRA support functions. Also completes social work assessments to support Social Work staff
  • Verifies patient eligibility based on line of business and associated benefits by utilizing appropriate software programs. Based on findings is able to connect patients to services available based on line of business
  • Improves the customer experience through the demonstration of Service and Courtesy Behaviors with a focus on Patient Satisfaction
  • Communicates directly with PCPs, specialists, community services and other programs on behalf of the patient and/or family
  • Processes internal and external program referrals as needed. Follows through as appropriate to ensure patient complies with referrals and services as recommended by the care team
  • Supports the patient through post hospital/post SNF discharge transitions. Makes outreach calls to High Risk/Most Vulnerable patients to validate that needed services were provided (i.e. receipt of DME, Home Health Visits completed, etc.) Escalates areas of concern to the CCDM

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