Dartmouth Health
Lebanon, NH, USA
46708242
Overview Facilitates the management of illness and health promotion. Provides assessment, information and referral, advocacy services, and other resource assistance to patients directly or through consultation. Manages a panel of moderate to high complexity patients for longitudinal Care Management. Responsibilities Manages and coordinates interdisciplinary care of defined populations through the care continuum from wellness through end of life from a psychological, social and environmental perspective. Partners with RN Care Managers for the management of patients with medical and social needs and barriers. Identifies high risk patients requiring on-going coordination of care; performs a comprehensive patient/family assessment, develops a comprehensive treatment plan that will span the continuum of psychosocial issues, implements a plan of care to provide continuing support and coordination for patient/family with multiple complex system needs Utilizes...