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Responsibilities: Identifies which patients in the specialty care practice have ongoing care coordination needs for their specialty condition. Outlines the nature and duration of involvement needed by the specialty care team and specialty care coordinator then identifies the primary care team involved. Utilizes assessment skills and risk assessment tools to identify patients with actual or potential care needs that would require care coordination. Conducts targeted outreach to a defined panel of high risk patients (chronic illness, lack of social support, readmissions, ED visits, surgical... more ->