** 2 weeks, maximum of training on site in Houston, then fully remote telephonic once fully trained**
Primary Responsibilities:
- Assess, plan, and implement care strategies that are individualized by member and directed toward the most appropriate, lease restrictive level of care.
- Identify and initiate referrals for social service programs, including financial, psychosocial, community and state supportive services.
- Manage the care plan throughout the continuum of care as a single point of contact.
- Communicate with all stakeholders the required health-related information to ensure quality coordinated care and services are provided expeditiously to all members.
- Advocate for patients and families as needed to ensure the patient’s needs and choices are fully represented and supported by the healthcare team.
- Perform telephonic and/or face-to-face clinical assessments for the identification, evaluation, coordination and management of member’s needs, including physical health, behavioral health, social services
- and long-term services and supports.
- Identify members for high-risk complications and coordinate care in conjunction with the member and the health care team.
- Manage members with chronic illnesses, co-morbidities, and/or disabilities, to insure cost effective and efficient utilization of health benefits.
- Assists in meeting member needs by referring members to internal and external resources.
- Provide follow up with internal and external resources, providers, and state programs.
- Provide input and/or data to direct supervisor/manager related to any internal or external mandatory audit or reporting.
- Serve as mentor, subject matter expert or preceptor to new staff.
- Involved in process improvement initiatives.
- Assist in problem solving with providers, claims or service issues.
MINIMUM QUALIFICATIONS:
- High School Diploma or GED
- 2 + years of experience in a health care role working within a community health setting with direct experience working with ABD/SSI client base.
- Experience in long-term care, home health, hospice, public health or assisted living.