Teams at Ampla Health

Leads enhanced care coordination for patients enrolled in CalAIM and transitions-of-care programs. Conducts outreach, assessments, discharge follow-up, medication adherence support, referrals, appointment coordination, and care-plan implementation. Collaborates with healthcare providers and community organizations, documents patient services, monitors program metrics, and advocates for patient access to medical and social resources.

Coordinate care for high-risk patients through California’s CalAIM initiative. Responsibilities include patient outreach and enrollment, post-hospital and emergency-room follow-up, assessments, individualized care plans, medication adherence support, health education, collaboration with care teams and community services, quality monitoring, record maintenance, and patient advocacy.

Coordinates patient referrals within a community health clinic by processing requests, scheduling appointments, tracking referrals, communicating with patients, insurers, and outside providers, maintaining EHR records and referral logs, and supporting quality improvement activities.