Landmark Health

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Psychiatric Patient Care Advocate

Psychiatric Patient Care Advocate

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Clinical Delivery Field
Regular Full-Time
Posted Date 
Job ID 

More information about this job


Do you want to make a difference in healthcare?

Landmark Health was created to transform how healthcare is delivered to the most medically vulnerable members in our community.  Our medical group provides home-based medical care to chronically ill patients, many of whom are frail, elderly and ill-equipped to navigate our overwhelming healthcare system.

Because many of our patients are frail and elderly, we deliver care primarily in the comfort of their home. Our Program is also offered to eligible patients at no incremental financial cost to them. We are not a fee-for-service practice; we benefit economically only if we deliver high-quality patient outcomes and satisfaction. As a result, our clinical teams can spend quality-time caring for a smaller number of patients, giving all patients the space, respect, compassion and care they deserve.

Our model is finding success throughout the country; we are now the nation’s largest risk-based, in-home medical group, with operations in six markets and four states across the country.

At Landmark, our interdisciplinary teams collaboratively manage our complex patient panels. These teams are led by Physicians, Nurse Practitioners, and Physician Assistants, with supporting care provided by RN Nurse Care Managers, Social Workers, Pharmacists, Behavioral Health and other employed team members.

The Care Advocate (CA) is responsible, as part of the care team, for the overall patient Care Management process. The CA works with the care team to provide , guidance and support for the patient care plan as developed through clinician, and allied clinical support evaluation and physical risk assessment completed by a Landmark provider.


The CA gathers information by telephonic interactions with patients. This information is used and helps guide treatment and care decisions of the team and also identifies services and vendors for needed care while navigating patient benefit plans. The A works collaboratively with a multidisciplinary team of PCP, specialists, Behavioral Health clinicians, midlevel practitioners, pharmacist, nutritionist  social worker and the patient, family and/or caregiver as they provide supportive care to enrolled patients.


The CA ensures that medical services are managed in the most effective and appropriate health care setting according to the patient’s medical condition.



  • Acts as an advocate for the patient in all activities including gathering clinical information , care coordination, and communication.
  • This position is accountable for identifying and developing innovative actions to meet the needs of the patient from both the health care and psychosocial / socioeconomic dimensions of care as well as taking action for provision of services to meet those needs.
  • Gather clinical information from the patient including obtaining medical records when available son all new enrolled patients, including a medical record review where available
  • Documentation of current advance care directive status and ongoing efforts to reconcile patient/caregiver misaligned goals with current clinical status
  • Perform ongoing interactions  with patient risk level and/or identified need
  • Collaborate with care team in Development of a plan of care to establish a approach to patient needs across clinicians and care delivery
  • Initiate and maintain ongoing communications with clinicians involved in patient care, especially PCP
  • Meet with families/responsible parties for collaboration on patient plan of care and discussion of patient/family/responsible party contribution to the ongoing management of patient condition as indicated
  • Coordinate care across the continuum of care delivery model as the point of contact for patient/caregiver and clinicians
  • Act as liaison between providers, nursing facilities, hospitals and program staff, including making recommendations about care alternatives or equipment that will aide in the safety of the patient while promoting optimal clinical outcomes
  • Monitor patient progress to plan of care goals with emphasis on patient care need during transitions and changes in patient level of care needs
  • Monitor patient during admissions to both acute and skilled level of care to support patient needs, establish as the point of contact to clinicians and patient/responsible party/families to ensure consistent and ongoing communication between all involved parties
  • Educate patients and/or families/responsible parties on disease processes and ways to manage disease progression as independently as possible
  • Reviews medical information collected including medical records and/or performs additional assessment to facilitate medical necessity determinations regarding service requests as established with in the identified program guidelines and the state established nurse scope of practice
  • Serve as a resource to the entire care delivery team
  • Identification and reporting of any quality of care issues including tracking and monitoring patient specific gaps in care
  • Maintain HIPAA compliance as it relates to patient care


  • 2-3 years of clinical experience in a hospital, clinic, home care, or nursing home setting
  • 1-2 years of utilization management experience a must
  • Case management experience desired
  • Disease management experience useful
  • Physician office experience helpful

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