Coordinates with physicians, staff, and non-Kaiser providers/facilities regarding patient care/population based management for patients in specifically defined geriatric or other specifically defined patient populations (e.g., patients with a specific chronic disease, high risk patients) in order to plan and implement a comprehensive, mutli-disciplinary approach to manage health conditions, utilization of resources and protocols, patient self-care, implementation and evaluation of treatment plan across the care continuum (primary, secondary, tertiary and continued care). In conjunction with physicians, develops treatment plan, monitors care, makes recommendations for alternative levels of care, identifies cost-effective protocols and care paths and develops guidelines for care that may require coordination across systems of multiple providers/services.

Essential Functions:
- Plans, develops, assesses and evaluates care provided to members.
- In conjunction with primary care and specialist physicians, evaluates and develops baseline medical and psychosocial evaluations and individualized patient care/treatment plans.
- Recommends alternative levels of care and ensures compliance with federal, state, and local requirements.
- Makes assessments of physiological and or functional status utilizing protocols.
- Initiates appropriate diagnostic testing/screening and interventions.
- Develops individualized patient/family education plan focused on self-management; delivers patient/family education specific to a disease state.
- Implements strategies to target/assess risk factors and achieve and ensure patient follow-up according to clinical and strategic measures/outcomes.
- Produces population based reports on outcomes specific to defined patient populations.
- Participates with healthcare team/providers in actualizing outcomes by planning, evaluating and implementing decisions and strategies to achieve predetermined cost, clinical, quality, utilization and service outcomes.
- Develops and maintains case management policies and procedures.
- Coordinates care/services with utilization and/or quality reviewers and monitors level and quality of care.
- Coordinates the interdisciplinary approach to providing continuity of care, including utilization management, transfer coordination, discharge planning, and obtaining all authorizations/approvals/transfers as needed for outside services for patients/families.
- Consults with internal and external physicians, health care providers, discharge planning and outside agencies regarding continued care/treatment or hospitalization or referral to support services or placement.
- Arranges and monitors follow-up appointments.
- Encourages member to follow prescribed course of care (e.g., drug therapy, physical therapy).
- Makes referrals to appropriate community services and outside providers.
- Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum.
- Develops and collects data; trends utilization of health care resources.
- Interprets regulations, health plan benefits, policies, and procedures for members, physicians, medical office staff, contract providers, and outside agencies.
- Coordinates transmission of clinical and benefit treatment to patients, families and outside agencies.
- Acts as liaison for outside agencies, non-plan facilities, and outside providers.
- Coordinates repatriation of patients and monitors their quality of care.