On Belay Health Solutions

Manager

• Develop trusting relationship with patients by providing support and advocacy to help achieve health goals Coordinate transitions of patients to/from acute inpatient, skilled nursing and other settings. Assist patients in accessing community resources (e.g., food stamps, meals on wheels, subsidized housing, free legal services, Medicaid/Medicare applications, support groups etc.) Meet with patients in patient-centered and patient-preferred locations (e.g., center, facility, home, community setting). Manage low-risk referrals defined by care management program (Medical Social Work) & collaborate with social worker on action plan Engage with high-risk individuals (e.g., completed specialty appointments, adherence to post-discharge visits); may include accompanying patients to appointments Assist completion of applications to access eligible benefits Perform wellness checks in homes, participate in remote monitoring program education on individuals with specific health conditions Provide health screenings, referrals and information Deliver health education presentations Facilitate communication between all identified parties by the patient involved in care (e.g., family members, care givers, medical providers, community-based organizations). Document interactions with patients in medical record Coach / train early career Care Managers, potentially in a management role Any other related duties assigned at manager’s discretion

Nurse Care Manager