Martinsburg, WV30+ days ago
Conducts telephone and face to face outreach to assigned patients to better their understanding of their health and the measures we are taking to manage their current health problems (chronic health problems, hospital discharges, etc.) as well as proactive measures to decrease future health risks. Collaborates with other members of the Primary Care Home Team (providers, health educators, nurses, social services, labs, specialists, hospitals, long term care facilities, etc.) to implement a plan of care for patients.