Responsibilities:

\nPerform comprehensive assessment of high risk members.\nCollaborate with primary care providers to ensure the implementation of an individualized, comprehensive care plan with specific interventions designed to engage the member.\nAddress, identify, and continuously reassess cost-efficient, appropriate levels of care.\nPut non medical support in place to ensure compliance with treatment plans (such as housing and transportation).\nCoordinate care transitions as needed.\nCoordinate with physicians, social workers, discharge planners, and claims professionals in transitioning patient to appropriate level of care.\nEngage specialty resources as needed to achieve optimal resolution.\nKeep detailed records of clinical, functional, and fiscal outcomes during the management process.\nIdentify opportunities for health promotion and illness prevention.\nent adverse patient occurrences when possible and intervene quickly if prevention is not possible, thereby minimizing poor outcomes.\nAct as patient advocate by protecting privacy and confidentiality issues.\n

Requirements:

License Requirements:

WV or compact\n

Productivity Requirement:

minimum 30points/wk\n

Required Skills:

HH experience, OASIS, HCHB experience\n

Qualifications:

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