1. General Summary

Responsible for identifying member gaps in care and implementing solutions to remediate them. Work closely with the RN Care Manager and other members of the Interdisciplinary Care Team to address post discharge and post-acute care needs, coordinate referrals and address social determinants of health. Provide a variety of administrative services to an assigned organizational unit. Work is performed under moderate supervision. Director report to the Nurse Manager, Population Health.

1. Principal Responsibilities and Tasks
   
   The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

• • Contact members by phone, mail and/or in person to educate them about their health care needs, gaps in care and the importance of closing those gaps.
  • Execute tasks for effective care coordination to improve patient care such (e.g., schedule follow-up visits and labs/tests, communicate with providers and case managers, and facilitate referrals and utilization, etc.).
  • Prepare documents and various materials, responds to correspondence and telephone inquiries, maintains filing systems, and prepares basic statistical data and reports.
  • Utilize various reports and data bases to assign cases to members of the care team.
  • Assist with health screenings and assessments and supports patient education related to social and health needs.
  • Provide scripted education/coaching and distribute health education materials (utilizing department approved resources) to patients and family members, as needed.
  • Screen patient using validated tools such as high-risk screeners, social determinants of health and PHQ 2-9.
  • Identify members who could benefit from case management and make appropriate referrals to the CM Program.
  • Conduct Transition of Care phone call to patients experiencing a transition along a care continuum such as post Emergency Department /hospital discharge, or post-acute care.
  • Work with the Interdisciplinary Care Team to provide support services and coordination of care activities to a defined population (e.g., post discharge phone calls, outreach phone calls to moderate and rising risk patients for screening into services, wellness checks, and education and follow up on care plan goals, etc.).
  • Provide education regarding scheduling routine wellness and screening appointments.
  • Adhere to standard volume of follow-ups, communicated productivity metrics, including length of call, length of answer time, and the number of calls taken or delivered to achieve first call resolution on every call.
  • Perform data entry in accordance with quality standards, including appropriate documentation and communication in accordance with compliance and regulatory requirements.
  • Manage a high-volume of inbound or outbound communication verifying and/or securing primary care visits, insurance coverage, etc.

• • Document the patient medical record and/or care management application.
  • Maintain HIPAA standards and ensure confidentiality of protected health information.
  • Perform other duties as assigned.