Communicate and provide resources to patient and caregivers about patient’s conditions and treatment requirements. Recognize and appropriately manage challenging behaviors of patient and caregivers. Liaise and follow through with patients and all health and social care providers to keep everyone informed and updated.  Organize patient information for efficient data transfer to relevant internal staff and external providers. Receive and collate information from new, existing and transfer patients. Liaise with other providers to ensure patients at risk are monitored adequately. Conduct checks on data input to ensure quality and consistency. Generate reports for population health management. Coordinate among multidisciplinary teams in the provider’s setting. Liaise with clinical and non-clinical staff for effective patient management. Organize and manage minutes of internal meetings as needed.

Follow up and tracking of preventive screening results to ensure the timeliness and completeness of follow-up as specifications and care-pathway