Comprehensive Rehabilitation Consultants (CRC)

• The LPN Care Coordinator will be responsible for delivery of Transitional Care and Chronic Care Management services allowing patients to thrive and progress toward desired outcomes. • Responsibilities include post-discharge patient outreach, patient-centered care plans, and service coordination utilizing software tools that facilitate communication and exchange of information with patients, CRC providers, and other care team members. • Detailed review of EMR record to inform initial outreach and care plan areas of focus • Perform comprehensive assessments for both physical and psychosocial risk factors that support individual patient needs while identifying and addressing barriers • Communicate assessment findings, care plan goals, interventions and outcomes to provider, patients, and caregivers in a timely manner • Monitor patient’s ED visits and acute stays, perform post-discharge follow up calls and continuously assess risk of readmissions post-discharge • Utilize motivational interviewing to promote patient engagement and empower patient to develop self-management skills • Provide chronic disease education and symptom management teaching to patients and caregivers • Communicate proactively with provider to address patient change in status or obtain any necessary referrals/orders • Document care plans, clinical interventions, and outreach in care management software system • Develop and maintain effective professional working relationships with assigned providers and other care management team members

• The LPN Care Coordinator will be responsible for delivery of Transitional Care and Chronic Care Management services allowing patients to thrive and progress toward desired outcomes. • Responsibilities include post-discharge patient outreach, patient-centered care plans, and service coordination utilizing software tools that facilitate communication and exchange of information with patients, CRC providers, and other care team members. • Detailed review of EMR record to inform initial outreach and care plan areas of focus. • Perform comprehensive assessments for both physical and psychosocial risk factors that support individual patient needs while identifying and addressing barriers. • Communicate assessment findings, care plan goals, interventions and outcomes to provider, patients, and caregivers in a timely manner. • Monitor patient’s ED visits and acute stays, perform post-discharge follow up calls and continuously assess risk of readmissions post-discharge. • Utilize motivational interviewing to promote patient engagement and empower patient to develop self-management skills. • Provide chronic disease education and symptom management teaching to patients and caregivers. • Communicate proactively with provider to address patient change in status or obtain any necessary referrals/orders. • Document care plans, clinical interventions, and outreach in care management software system. • Develop and maintain effective professional working relationships with assigned providers and other care management team members.

• Build, tune, and validate statistical models including multi-stage regression, ordered probit, and generalized linear models, audit automation, acuity scoring, and financial forecasting • Engineer features from structured and unstructured healthcare data (EMR, claims, revenue cycle, clinician notes) • Tune the existing CRC NLP engine for clinical note understanding, keyword extraction, concept expansion, negation detection, and sentiment scoring • Build custom clinical embeddings using HuggingFace Transformers, spaCy, and domain-tuned vector models • Develop and maintain a CRC private LLM, trained on internal knowledge bases, documentation, analytics logic, and care guidelines • Build automated pipelines for LLM evaluation, retraining, retrieval-augmented generation (RAG), and grounded QA • Architect, build, and deploy the AI Analytics Chatbot, integrating model logic, business rules, and Fabric/Databricks data sources • Integrate ML models into production services using notebooks, APIs, or batch inference jobs • Support creation of AI-generated reporting, insights summaries, and automated clinical/financial narratives • Build maintainable ML pipelines (training, validation, deployment) using Databricks, Fabric, MLflow, GitHub, and CI/CD • Implement model monitoring, drift detection, and automated retraining • Package and deploy reproducible models via APIs or scheduled Fabric/Databricks workflows • Work with data engineering to embed models into CRC applications • Partner with BI analysts to transform model outputs into dashboards • Document methodologies, assumptions, architecture, and validation processes clearly