Work telephonically and in the field with patients identified as high risk to identify needs, set goals and implement action steps towards achieving goals. Empower patients to help them improve their quality of life.
Utilize the Client Information System (CIS) to document and track outcome measures, regular documentation and progress notes, demographic documentation and Child Functional Assessment Rating Scale (CFARS).
Perform duties related to the day to day operations of the Integrated Case Management functions to include working with members identified as high risk to identify needs and goals to achieve empowerment and improved quality of life for both behavioral and physical health issues.
Developing, executing and coordinating member's plan of care, with an emphasis on the most complicated cases; identifying members and episodes (such as care transitions) that would most benefit from care coordination based on program objectives and members' risk.