Responsibilities

• Addresses member’s problems and needs from a clinical, psychosocial, financial and environmental stand point.
• Provide services to members of varying age, risk level, clinical scenario, culture, financial means, social support, and motivation.
• Engage members in a collaborative relationship, empowering them to self-manage their physical, psychosocial and environmental health to improve and maintain lifelong well-being.
• Prepare member-oriented plan of care with member, caregivers, and health care providers, integrating concepts of cultural sensitivity and privacy practices.
• Participates in interdisciplinary meetings.
• Ensure plans of care have individualized goals and interventions.
• Discusses Members’ plan of care to Primary Care Physician and/or Medical Specialists.
• Address gaps in care with the member/caregiver and provider.
• Addresses members social determinants of health issues.
• Link members to available community resources.
• Provide care management support during Transitions of Care
• Ensure member/caregiver understanding as it relates to language barriers and stress reaction or cognitive limitations/barriers.
• Educates Members on relevant chronic diseases, preventive care, medication management (medication reconciliation and adherence), home safety, etc.
• Provide Complex care management including but not limited to; ensuring access to care, reducing unnecessary hospitalizations, and appropriately referring to community supports.
• Advocate for members by assisting them to address challenges and make informed choices regarding clinical status and treatment options.
• Maintain accurate, comprehensive and current clinical and non-clinical documentation in computer data base.
• Employ critical thinking and judgment when dealing with unplanned issues
• Comply with all orientation requirements, annual and other mandatory trainings, organizational and departmental policies and procedures, and actively participate in the evaluation process.