This job was posted by https://www.azjobconnection.gov : For more information, please see: https://www.azjobconnection.gov/jobs/6582757

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.