Manage assigned member caseload telephonically Complete home engagement visits, when telephonic outreach attempts (3), are unsuccessful. Create a positive experience and relationship with the member Keep the member out of the hospital by supporting regular visits to their primary physician Keep member actively engaged with their primary physician Support the member to ens

Perform telephonic customer outreach to improve health quality outcomes in collaboration with clinical pharmacists Provide additional telephonic engagement with providers and pharmacies Assess and interpret customer needs and requirements, triaging to a clinical pharmacist when appropriate Document and track member engagement You'll be rewarded and recognized for your per

Review and assess individual member clinical cases for high priority medication related opportunities and recommendations Provide written, consultative medication recommendations for interdisciplinary care management team members Directly contact medical providers over the telephone as needed to discuss pharmacy related consultative recommendations and provide benefit rel

Collect pertinent patient data (e.g., vital signs; complaints; medications and allergies; health screening information) in order to identify care needs Provide relevant medical services/care as directed by physicians (e.g., injections; procedures; treatments) Support and/or coordinate safe transportation of patients to and from medical appointments/facilities (e.g., drive

Review applications, gather data, determine eligibility and compliance Process broker and agent licensing, appointment and contracting credentials for Medicare Supplement Products Ensure that all paperwork, credentials and other necessary documents are in good order Perform analysis of submitted material for completeness and accuracy, analyzing, credentials and documentat

Perform initial and ongoing reviews pertaining to primary role (PA, ICM, DCM, PACM), appropriately applying clinical criteria (InterQual, policies, National and Local Coverage Determinations) for approval and sending to Medical Directors if review is necessary for determining an adverse determination Collaborate with Medical Directors, clinical peers and Health Plan partn

Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, lease restrictive level of care Identify and initiate referrals for social service programs; including financial, psychosocial, community and state supportive services Manage the care plan throughout the continuum of care as a single point of contact Com

Support case and disease management teams to achieve optimal clinical outcomes for high risk populations Proficient in evidence based clinical guidelines and lead grand round clinical education sessions with nursing teams Primary functions include RN case manager support and consultation about high risk members and assisting in account management team presentations Be inv

Responsible for developing and preparing documentation for NCQA and other accreditation survey submissions Works closely with regional quality staff, health plan staff, and internal business partners to build and document compliance with accreditation standards Interpret complex data and draws conclusions Complete reports that provide analysis of data related to key quali

Engage members face to face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic needs Develop and implement person centered care plans to address needs including management of chronic health conditions, health promotion and wellness, social determinants of health, medicati

Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, at least restrictive level of care Identify and initiate referrals for social service programs; including financial, psychosocial, community and state supportive services Manage the care plan throughout the continuum of care as a single point of contact

Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, lease restrictive level of care Identify and initiate referrals for social service programs; including financial, psychosocial, community and state supportive services Manage the care plan throughout the continuum of care as a single point of contact Com

Provide skilled nursing care for expectant mothers in the home care environment Travel to provide in home patient care and continuous education to patients and family members Continually assess the mothers' condition to ensure they are safe in the home environment Modify care plans as appropriate based on reassessment, change in prescriber orders, the patient's need for f

Assess, plan, and implement care strategies that are individualized by patient and directed toward the most appropriate, lease restrictive level of care Identify and initiate referrals for social service programs, including financial, psychosocial, community and state supportive services Manage the care plan throughout the continuum of care as a single point of contact Co

Use of own Recovery experience and training to assist families and consumers with defining their Recovery goals, and developing the skills and knowledge needed for the consumer's recovery Experience working with consumers that have co occurring Disorder, i.e., Mental Health and Substance Use Disorder Support the creation and assist with the implementation of a comprehensi