Provides in person and or telephonic Care Management Services to identified high risk members within the community including but not limited to Physician Practices, Neighborhood Care Centers, and members’ homes. Coordinates and provides care that is safe, timely, effective, efficient and member centered to support EH population health complex care management initiatives. Engages with the most complex members of the health plan with the goal of improving health care outcomes and appropriate and timely utilization of services across the continuum of care. Coordinates care as needed with our embedded and field-based care managers.
- Assesses and evaluates member’s needs of our most complex members, coordinating care utilizing the most appropriate resources to support member needs. Includes member and family as appropriate. Engages actively with the member PCP /designee.
- Engages with the member in support of their treatment team to identify and establish attainable goals that positively impact clinical, financial, and quality of life outcomes for member.
- Assesses the needs of members and aligns them with the appropriate member of the care team (wellness team, registered dietitian, social worker).
- Monitors care team performance to insure members are engaged in a timely fashion and that performance metrics (Admits/K, ER utilization etc) meet or exceed established thresholds.
- Provides ongoing monitoring, evaluation, support and guidance to the coordination of the member's health care.
- Implements and coordinates plan of care and facilitates members goals.
- Serves as an informal leader of the team with the goal of maintain team performance and high morale.