Job descriptionInfinit-O is the trusted, customer-centric, and sustainable leader in Business Process Optimization. We empower finance and healthcare organizations to thrive in a digital-first world by combining specialized industry expertise and innovative technology for 20 years.
We navigate complex industry landscapes to drive transformative outcomes, helping businesses streamline operations, enhance customer experience, and achieve sustainable growth backed by a world-class Net Promoter Score of 75. Our approach combines operational efficiency with a human-centered ethos, ensuring sustainable value creation for our clients and team members.
As a Certified B Corporation, Infinit-O is committed to the highest standards of social and environmental performance, accountability, and transparency. We embed these values into every aspect of our operations—aligning business success with a positive impact on our clients, people, and communities.
Our commitment to Diversity, Equity, and Inclusion (DEI) is integral to our mission. We believe that building inclusive, equitable teams is not only the right thing to do—it is also essential for driving innovation and better business outcomes. We actively promote equal opportunity through inclusive hiring practices, continuous learning programs, and regular equity assessments to ensure a fair and empowering workplace for all.
Key Responsibilities:1. Care Coordination & Management
●Caseload Management: Manage an assigned caseload of patients (, Medicare/Medicaid beneficiaries), ensuring regular contact frequencies are met according to acuity levels.
● Resource Linkage: Act as the liaison between the patient, primary care providers (PCPs), specialists, and community resources to close gaps in care.
● Barriers to Care: Identify Social Determinants of Health (SDOH) such as transportation or financial issues and coordinate with social workers or community liaisons to resolve them.
● Documentation: Maintain accurate, comprehensive, and compliant documentation of all patient interactions in the Electronic Health Record (EHR) in real-time.
2. Transitions of Care (TCM)
● Admission/Discharge Tracking: Monitor patient census to identify hospital admissions and discharges daily.
● Post-Discharge Follow-up: Conduct telephonic outreach within 24–48 hours of discharge to reconcile medications, review discharge instructions, and schedule follow-up appointments with PCPs.
● Red Flag Monitoring: Assess patients for worsening symptoms post-discharge to prevent unnecessary hospital readmissions (ER utilization).
3. Care Planning & Assessment
● Comprehensive Assessment: Conduct telephonic clinical assessments to gather data on medical history, functional status, and psychosocial needs.
● Care Plan Development: create individualized, patient-centered care plans with specific, measurable, achievable, relevant, and time-bound (SMART) goals.
● Regular Reviews: Periodically review and update care plans based on patient progress, changes in health status, or after a transition of care event.
● Patient Education: Educate patients and caregivers on disease processes (, Diabetes, CHF, COPD), medication adherence, and self-management techniques.