SYDIERA

Nurse Practitioner

• Provide clinical care and ongoing management through telehealth and remote care technologies
• Manage medically complex Medicaid and Dual Eligible patient populations
• Collaborate with physicians and an interdisciplinary care team to develop and execute individualized care plans
• Build relationships with patients, families, caregivers, primary care providers, specialists, and health plan partners
• Identify changes in patient condition and intervene early to help prevent unnecessary emergency department visits and hospitalizations
• Support patients during hospital admissions, discharges, and transitions back home
• Participate in advance care planning and goals-of-care conversations with patients and families
• Participate in a shared clinical triage and support model
• Help shape a new model of care for medically complex patients at home

• Provide clinical care and ongoing management through telehealth and remote care technologies
• Manage medically complex Medicaid and Dual Eligible patient populations
• Collaborate with physicians and an interdisciplinary care team to develop and execute individualized care plans
• Build relationships with patients, families, caregivers, primary care providers, specialists, and health plan partners
• Identify changes in patient condition and intervene early to help prevent unnecessary emergency department visits and hospitalizations
• Support patients during hospital admissions, discharges, and transitions back home
• Participate in advance care planning and goals-of-care conversations with patients and families
• Participate in a shared clinical triage and support model
• Help shape a new model of care for medically complex patients at home
• Coordinate care through telehealth, remote care management, and collaboration with patients, families, caregivers, health plans, and primary care providers