Our Mission:
CircleLink Health® is a company of passionate clinicians, technologists and business people tackling the $600B problem of preventable chronic condition complications. Our mission is to accelerate the shift to preventative care (from status quo reactive care) through our world-class preventative care platform.
Your Impact On Our Mission:
As a Care Coach you will work remotely for 20-25 hours per week with a team of nurses to manage patients with chronic conditions enrolled in Medicare’s Chronic Care Management program.
Your day to day is…
• Educating patients on self-management skills and goal setting. Chronic conditions include: Diabetes, CHF, COPD/Asthma, Hypertension, CAD, Ischemic Heart Disease, Anxiety, Depression.
• Implement and improve the Plan of Care by updating medications, appointments due, record biometrics, vital signs, and care coaching provided.
• Utilize Motivational Interviewing or other behavior change techniques to coach and assist the patient with self-management.
• Conduct Transitional Care Management activities to high risk patients discharged from the hospital and the ER to reduce unnecessary readmissions, including medication reconciliation, medication adherence, identify red flags, address barriers, encourage follow-up care, how and when to seek appropriate level of care.
• Reduce care gaps by encouraging or assisting with preventive care, and chronic care management, i.e. annual well visits, follow up visits, medication management, pre-visit labs, diagnostic tests due, preventive cancer screens.
• Connect the patient with community resources as needed, including transportation, personal care needs, homemaker or chore services, social services, etc.