Corpus Christi, TX9 days ago
Ensure clinicians effectively co-manage high risk episodes of care and patients with partnered Care Integration Team (CIT) resources and programs for transitions of care management (TCM), high-risk patient management (HRPM), and social determinants of health (SDOH) efforts, improving clinical outcomes and avoidable utilization . •Personally deliver high-quality primary care and demonstrating a high degree of patient care ownership and clinical excellence in age-friendly senior primary care including health promotion & prevention, disease management, effective specialist & hospital co-management, and complex care management .