Responsible for the assessment, reassessment, care planning and coordination of care and services. Includes ongoing monitoring of an appropriate and effective person centered care plan, member education and care management. Regularly communicates with the members' PCPs and other providers, and integrates the member, caregiver and other provider feedback into the assessment and planning.
Ensures continuity of care for newly enrolled members.
Identifies and prioritizes the members' needs and preferences.
Develops quantifiable goals and desired outcomes, and promotes the members' ability to self-manage to the greatest extent possible.
Develops, implements and monitors the Person Centered Service Plan, assisting members in obtaining reasonable accommodations when appropriate.
Manages case load, including risk stratification of members, monitoring reassessment needs and facilitating transitions of care settings.
Serves as the primary point of member contact.
Assesses member needs, manages care and services, and ensures effective communication among members, caregivers, providers and community supports.
As the lead of the interdisciplinary team, facilitates the activities and communication within an interdisciplinary team of providers, vendors, facilities, discharge planners, field nurses, social workers, care coordinators, and member/caregivers to effectively manage care plans and transitions of care settings.
Maintains timely, complete and accurate documentation using both hard copy and technology based solutions in compliance with regulatory policies and procedures.
Gathers and summarizes data for reports.
Supports initiatives of the Quality Assessment and Performance Improvement Committee.
Understands and is able to apply principles of Care Management and Person Centered Service Planning.
Ability to apply Milliman Care Guidelines and other applicable, evidenced-based clinical guidelines.
Ability to understand and apply coverage guidelines and benefit limitations.
Familiar with clinical needs and disease processes for chronic physical and behavioral illnesses (depression, challenging behaviors, Alzheimer's disease and other disease-related dementias).
Understands and adapts appropriately to issues related to communication, cognitive or other barriers.
Ability to lead an interdisciplinary care team.
Strong organizational skills and the ability to prioritize and follow through on multiple projects in a timely manner.
Comfortable with conducting home visits and commuting within the service area.
Minimum 3 years' clinical experience with focus in managed care, including disease or case management.
Home Care, Long-Term Care, MLTC experience preferred, including appropriate support services in the community and accessing and using durable medical equipment (DME).
Experience in utilization review, concurrent review and/or risk management a plus.
Bilingual or multilingual fluency preferred.