About the job
KEY RESPONSIBILITIES:
- Conduct comprehensive health risk assessments and needs evaluations, incorporating psycho-social, physical, medical, behavioral, environmental, and financial factors.
- Develop and communicate treatment plans for service authorization and act as the primary contact to ensure appropriate provision of services during transitions to home care and community-based programs.
- Implement and monitor strategic initiatives aimed at enhancing health outcomes and quality of life for members and their families. Document and execute plans to provide suitable resources addressing social, physical, mental, emotional, spiritual, and support needs, while advocating for members by identifying and addressing care gaps.
- Regularly assess and review care plans to identify gaps, trends, and areas for improvement, working collaboratively with members and the interdisciplinary team to adjust care strategies as necessary.
- Educate healthcare providers and support staff on care coordination roles and health strategies, ensuring a member-centered approach to care and facilitating effective teamwork in delivering high-quality, cost-effective services.
- Collaborate with the Interdisciplinary Care Plan Team (ICPT) to ensure the delivery of appropriate interventions across the care continuum, engaging with members, caregivers, legal representatives, physicians, and support services to address complex care needs.
- Assist members with inquiries regarding their care, providers, and the delivery system.
- Maintain professional relationships with external stakeholders, including inpatient and outpatient resources.
- Generate reports aligned with care coordination objectives.
- Adhere to the Case Management Society of America Standards for Case Management Practice and the CCMC Code of Professional Conduct.
- Support the orientation and mentoring of new team members as required.

