General Job Functions:

• Provision of high quality and compassionate care for medically and socially complex, elderly and home bound patients.
• Has knowledge of and/or is willing to learn all phases of care transitions and resources available for patients.
• Ability to solve complex problems and troubleshoot care needs.
• Comfortable conversing with patients and families about goals of care and coordinating with the JMMG Palliative Care team when appropriate.
• Proficient in working independently and in a multi-disciplinary team environment.
• Resolves routine administrative issues independently and in a timely manner.
• Assists with special projects and other duties as requested

Essential Job Responsibilities:

• Visits patients in their homes for monitoring vital signs, performing the history and physical examinations, reconciling medications, and developing care/treatment plans independently or in coordination with a supervising physician.
• Manage and triage medical queries and urgent issues from home visit patient panel via telephone encounters or urgent- and same-day home visits.
• Coordinate and communicate with the care team involved with each patient.
• Participate in care management by coordinating and meeting with outpatient case management services.
• Participate in an on-call system to address homebound patient issues during night and weekend hours.
• Participate in other JMMG Transitional Care programs as needed.
• Identify issues in the program that require enhancement and optimization.