Job DescriptionJOB SUMMARY: This role coordinates care of the Care Transformation Organization (CTO) assigned Medicare patients within the primary care provider's office. Works with an interdisciplinary team to manage care and coordinate care services attributed to partisan practices. Assess psychosocial needs and functional deficits of the patient and informs providers of changes in the care plan and/or patient's condition. Through an integrated approach, this role completes intake assessments, assists with the treatment planning, monitors patient progress, facilitates patient and family meetings, and coordinating and implementing of treatment referrals. This position plans and organizes community-based services tha