About this role
About the Role: Provide a link between patients and available resources to provide the necessary resources in a cost-effective manner. Our Values: Put Patients First Empower Entrepreneurial Provider and Care Teams Operate with Integrity & Excellence Be Innovative Work As One Team Provide home visits to risk patients and families for evaluation of needs in an effort to provide direction of care for desired outcomes in a cost-effective manner. Report specific health & social information back to the care management team to asset in development of care pathways. Participate in multidisciplinary team conferences as needed. Assist patients with accessing needed services, recognize potentially serious problems to prevent poor health and social outcomes.