Job Description

Agency for Integrated Care (AIC) funded programme initiative, with focus on integrated physical and mental health support across community networks.

Coordinate comprehensive care for patients with complex needs, serving as the primary liaison between community partners and hospital systems to ensure seamless care transitions and continuity.

Perform miscellaneous job-related duties as assigned.

Key Responsibilities:

  • Care Coordination: Manage patient care plans across hospital and community settings, including discharge planning, appointment monitoring, and care transitions
  • Community Partnership: Collaborate with community partners for patient follow-up, home visits, and resource linkage
  • Patient Education: Provide psychoeducation on medication compliance and empower patients in self-care management
  • Administrative Support: Manage referrals, schedule meetings, maintain programme databases and performance indicators
  • Dat...

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