Assessment & Planning
May conduct comprehensive assessments, which could include physical, psychosocial, and health literacy evaluation, and interprets relevant diagnostic data to identify member and family needs.
Apply critical thinking skills to analyze complex cases, complete medication reconciliation post-discharge, and determine underlying causes contributing to high costs as applicable. Uses these insights to inform individualized transition/treatment plans and address gaps in care delivery.
If applicable, partners with and empowers the member to develop an actionable care plan that helps prevent avoidable utilization.
Care Delivery
Consistently follows through on all essential tasks and completes them within required timeframes to effectively close care gaps.
Communicate results to internal and external departments and business partners as applicable.
Communication & Education
If applicable, assesses educational needs of members and families, ensuring clear and sufficient information is provided to facilitate active participation in care gap closure.
Quality Improvement & Leadership
Engages in quality improvement initiatives, supports leadership in system-level improvements, analyzes dashboard data for program enhancement, and mentors new staff to promote best practices.
Performs all other miscellaneous responsibilities and duties as assigned or directed.
#LI-Hybrid