Description Essential Functions Conducting regular telephonic outreach to UHACO members with a focus on coordinating individual patient care by partnering with members of the health care team to develop individual, trusted relationships with patients to guide them through: * Routine preventive care, health maintenance visits, and diagnostic services * Hospitalization and post-discharge services including the use of Home Care, SNF, Rehabilitation, Palliative and Hospice levels of care * Reducing risk factors and barriers to care, addressing complex, co-morbid conditions, and social determinants of health * Developing longitudinal care planning that includes assessment, planning, implementation and monitoring * Coordinating continuity of care with patients and families following hospital admission, discharge and ER visits * Providing health and disease education to patients and families * Engaging at risk members to develop specific care plans to address health concerns, gaps in care and individual challenges in order to achieve an optimal level of wellness and functional capability Demonstrating a thorough understanding of, and ability to connect patients with, available resources in the Northeast Ohio community focused on improving the health, wellness, and overall quality of life for a patient. Analyzing various sources of data to identify at risk patients and member groups, then developing specific care plans to address health concerns, gaps in care, and other challenges. Partnering with UHACO team members to support patients, their families, and physicians in addressing barriers to medical care. Connecting UHACO members with various UH Population Health team resources to improve the patient experience of care (including quality and satisfaction); improve the health of populations; and reduce the cost of health care Required For All Jobs Performs other duties as assigned. Complies with all policies and standards. For specific duties and responsibilities, refer to documentation provided by the department during orientation. Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace. Equal Opportunity Employer -- minorities/females/veterans/individuals with disabilities/sexual orientation/gender identity