This job was posted by https://www.azjobconnection.gov : For more
information, please see: https://www.azjobconnection.gov/jobs/6512277
Assist the patient-centered medical home inter-disciplinary team and
patient with development of care plans, coordination of services and
addressing social determinants/barriers to care. Follow-up with high
risk patient populations, including care transitions and those patients
with multiple chronic conditions, to review care plans and goals,
updating as outcomes are achieved or additional goals or barriers are
identified. Works with the patients and families to access resources and
adopt healthy lifestyles.