Job Details

Responsibilities:Care Coordination & Follow-UpOversee and track referrals, transitions of care, and care plans to ensure timely completion and resolutionConduct proactive outreach to members via phone, text, and digital platforms to support adherence to care plansIdentify and address barriers to care, including transportation, financial challenges, access issues, and social needsCoordinate services across providers, specialists, and community-based organizationsClosed-Loop Referral ManagementMonitor referral status and ensure completion of feedback loops with appropriate documentationFollow up with providers and service partners to confirm appointment attendance, outcomes, and next stepsEscalate delayed or unresolved referrals in accordance with established protocolsMember Engagement & EducationEducate members and caregivers on care plans, follow-up steps, and available resourcesSupport members in navigating resources and accessing community-based servicesUtilize motivational interviewing and culturally responsive communication to improve members engagement and outcomesDocumentation & Data ManagementAccurately document all patient interactions, referrals, and outcomes within the data system or care management platformEnsure compliance with organizational policies, HIPAA, and regulatory requirementsTrack and report key performance metrics, including referral completion rates, follow-up timelines, and care gaps closedAdditional Details:Schedule: Monday - Friday 9:00am - 5:30pm EST MUST have Ethernet connection - Strong internet/wifi connection is a hard requirement