Pittsburgh, PA30+ days ago
n\n Identify and address barriers to improved health outcomes for medically complex patients.\n \n\n Implement systematic strategies for assessments, enrollment, care planning, documentation, and value measurement for patient care.\n \n\n Participate in a multidisciplinary team to integrate primary and behavioral healthcare services.\n \n\n Offer ongoing consultation with treatment teams, hospitals, specialty providers, pharmacies, insurance companies, patients, and families.\n \n\n Provide crisis intervention as needed.\n \n\n Educate patients and hospital staff about the Medical Respite program and participation expectations.\n \n\n Conduct medication reconciliation and provide medication education in partnership with providers and pharmacy staff.\n \n\n Develop and facilitate chronic disease management and healthy lifestyle programs using evidence-based practices.\n \n\n Coordinate internal and external care, including specialty care, tobacco cessation, housing, transportation, and health benefits.\n