Job Description
Key Responsibilities:
Provide telephonic care management, support, and education to patients, families, and caregivers aligned with the established care plan.
Collaborate with physicians, providers, and interdisciplinary teams to create and implement integrated, individualized care plans.
Use motivational interviewing and solution-focused communication to engage beneficiaries and encourage self-management.
Monitor patient progress, assess care effectiveness, and refine strategies using data-driven insights.
Identify and address barriers to care, including Social Determinants of Health (SDOH), by connecting patients with appropriate community resources.
Support quality performance initiatives by driving improvements in patient engagement, care outcomes, and clinical metrics.
Reduce preventable hospital readmissions through timely interventions and comprehensive care planning.
Demonstrate critical thinking, sound clinical judgment, and adaptability in dynamic care situations.
Meet departmental performance targets, including daily call quotas and caseload management.
Maintain strict adherence to confidentiality, patient advocacy, safety protocols, and regulatory standards.
Actively participate in ongoing professional development and stay current with best practices in case management and chronic care coordination.
Required Skills and Qualifications:
Registered Nurse (RN) with current licensure in applicable state
Bilingual English/Spanish required
Strong clinical knowledge in chronic disease management
Proficient in care coordination, patient education, and telephonic nursing
Skilled in motivational interviewing and collaborative care planning
Excellent organizational, time management, and critical thinking abilities
Knowledge of SDOH and experience navigating community resources
Commitment to maintaining high ethical and professional standards
The Bachrach Group LTD. (TBG) has been building better workforces with extraordinary talent based on specific functional experience, one position at a time, for nearly 50 years. Our commitment to sourcing top-notch talent has made us national leaders in both staffing and executive search.
The Bachrach Group LTD. (TBG) has been building better workforces with extraordinary talent based on specific functional experience, one position at a time, for nearly 50 years. Our commitment to sourcing top-notch talent has made us national leaders in both staffing and executive search.
...experienced Van or Refrigerated Freight driver to join our team. Start the new year off... ...provides. With decades of experience in the transportation industry, our Load Planning, Driver... ...01(k) matching * Dental insurance * Fuel card * Health insurance * Paid time...
...inclusion and equity, and welcome employees, faculty and students from all faiths and cultures... ...clinical rotations for the Family Nurse Practitioner (FNP) students. CAF are hired... ...Complete an end of semester student evaluation online Notify course faculty promptly...
...Job Description Job Description Construction Superintendent With 50+ years in business, we are a 300 person, ENR TOP General Contractor and have a wide range of construction projects. We are currently hiring for an experienced Superintendent with a heavy focus...
...prestigious educational institution in Boston is seeking a Seasonal Gardener for a six-month term appointment. The role involves hands-on horticulture tasks such as lawn maintenance, pruning, and transplanting. Candidates should have at least one year of horticulture experience...