PharmD Live

General

• Conduct virtual outreach with patients to review care plans and provide education
• Monitor patient health status via RPM tools and escalate clinical concerns appropriately
• Document all interactions in compliance with CMS, payer, and internal quality standards
• Coordinate post-discharge follow-up and specialist appointments
• Collaborate with nurses, pharmacists, and other care team members to optimize outcomes
• Foster patient engagement, adherence, and trust through empathetic communication

LPN/LVN

• Conduct high-volume outbound and inbound patient calls during scheduled shift
• Schedule Annual Wellness Visits and care management appointments
• Provide professional patient education regarding preventive services
• Meet daily outreach and scheduling performance targets
• Perform medication reconciliation with patients
• Update medical histories, allergies, and preventive care gaps
• Collect and document patient-reported vitals when applicable
• Prepare charts for provider review
• Ensure accurate documentation within the EHR
• Support care coordination and follow-up activities
• Maintain HIPAA compliance at all times
• Accurately document all patient interactions in the EHR
• Escalate clinical concerns to supervising providers as appropriate

Medical Assistant – Part-Time

• Conduct outbound and inbound calls to educate patients on CCM, RPM, and related clinical programs
• Clearly explain program benefits, eligibility, consent, and expectations
• Successfully enroll patients during live interactions while addressing objections and questions
• Schedule patient appointments with clinical pharmacists and care teams
• Ensure smooth handoffs between enrollment and clinical operations
• Respond promptly to patient inquiries via phone, voicemail, and email
• Communicate with provider offices and insurance representatives as needed to support enrollment
• Accurately document all patient interactions in accordance with CMS, HIPAA, and internal quality standards
• Ensure consent, eligibility, and enrollment data are complete and audit-ready
• Partner cross-functionally with clinical, operations, and quality teams
• Meet or exceed enrollment, call volume, and quality benchmarks
• Participate in training, coaching, and continuous improvement initiatives

Patient Enrollment Specialist

• Conduct comprehensive AWVs for Medicare beneficiaries via secure telehealth platforms
• Facilitate structured ACP discussions, documenting patients’ goals and care preferences
• Review medical histories, medications, functional and cognitive status, and preventive care needs
• Identify and close care gaps by guiding patients on screenings, vaccinations, and chronic disease management
• Collaborate with interdisciplinary care teams and primary care providers to ensure coordinated, patient-centered care
• Maintain timely, accurate documentation in the EHR
• Adhere to CMS guidelines and clinical quality standards

Nurse Practitioner / Physician Assistant – Hawaii Licensed

• Deliver scheduled chronic care outreach and patient check-ins
• Reinforce care plans, treatment goals, and self-management education
• Monitor RPM data and identify trends requiring clinical intervention
• Coordinate follow-up care after hospitalizations or specialty visits
• Communicate effectively with interdisciplinary care teams
• Document all patient interactions accurately and compliantly
• Support adherence by identifying and addressing patient barriers

Chronic Care Management LPN/LVN, Virginia License

• Conduct comprehensive assessments, develop and adjust individualized care plans, and provide patient-centered education, clinical oversight, and support in collaboration with a multidisciplinary care team.
• Perform detailed medical, psychological, and social assessments to identify patient needs and risks.
• Diagnose, evaluate, and manage chronic conditions in accordance with current clinical guidelines.
• Develop, implement, and modify personalized care plans that optimize patient outcomes.
• Collaborate with physicians, pharmacists, and care managers to ensure integrated, coordinated care.
• Counsel patients on disease management, medication adherence, lifestyle modification, and preventive care.
• Use motivational interviewing and behavior-change strategies to engage patients in their health journey.
• Facilitate seamless communication among patients, caregivers, and the healthcare team.
• Review test results, monitor disease progression, and provide follow-up to prevent complications or gaps in care.
• Monitor RPM data for early warning signs and initiate timely clinical interventions.
• Document all patient encounters, care plans, and interventions in the EHR accurately and promptly.
• Ensure compliance with CMS and other regulatory requirements for CCM and RPM.
• Oversee patient enrollment into CCM and RPM programs.
• Support quality improvement initiatives, program effectiveness, and patient satisfaction tracking.

Physician Assistant, Nurse Practitioner

Manager

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