Remote Care Manager CCM/RPM/BHI

CCM/RPM The ideal candidate works in collaboration and continuous partnership with chronically ill patients and their family/caregiver(s), clinic/hospital/specialty provider and staff, and community resources in a team We are seeking a bilingual and remote care manager to join our rapidly growing team at Preventel Health performing Chronic Care Management (CCM), Remote Patient Monitoring (RPM) and Behavioral Health Integration (BHI) by telephonically delivering health and wellness calls to assigned patients.

Remotely providing basic patient coaching and care to improve patient outcomes Develop a care plan with the patient, family/caregiver(s) and provider Monitor patient outcomes, adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner and facilitate changes as needed Coaching and educating patients on improving their Chronic Conditions, preventive care and physician directives Telephone outreach to English and Spanish-speaking patients Facilitate CCM, RPM and BHI program enrollment Concise and accurate documentation Cultivate and support the primary care providers with timely communication, inquiry follow-up, and integration of information into the care plan regarding transitions-in-care and referral