Position Summary: Accountable for engaging with patients and their family in telephonic-based Care Management. This role will provide care mangement to different targeted populations in various program arrangements., including but not limited to, management of care transitions, longitudinal care management and disease based care management. Works under direct supervision and is a part of an interdisciplinary Care Management team. Responsible for end to end comprehensive care management, overall care planning and performance metrics for assigned caseload.

• Engages with patients and their family, and members of the health care delivery team about goals of care and the care plan; knowledgeable about level care of needs, community resources, and insurance benefits, so that appropriate referrals and resouce linkages can be made to support ongoing self-care needs.
• Demonstrates and understanding of care mangement, complex disease management, transitions of care, post-acute care landscape/options, and community management standards. Maintain familiarity with community resources and agencies for assigned locality and update resouces as necessary.
• Demonstrates an understanding of current climate of economics and funding resources for care delivery/care management. Utilizes resources efficiently and effectively.
• Demonstrates an understanding of managed care trends, payer regulations, remibursement, and the effect of utilization on the different methods of reimbursment.
• Works as part of interdisciplinary "team rounds" to address utilization/resources and progession of care issues. Assists in developing and implementing an improvement plan to address issues.
• Adheres to communincated care mangement productivity metrics, and maintenance of caseload as per policy. Adheres to quality standards, including adherence to model of care/standard operating procedures as well as comprehensive documentation, actionable care plans, and appropriate cases closed in a timely fashion.
• Develops strong working relationships with internal and external customers to provide exemplary service and achieve goals.
• Proficiency in various word processing, spreadsheet, graphics, and database programs, including Microsoft Word, Excel, PowerPoint, Outlook etc...
• Demonstrates the abiiity to evaluate utilization/ resource/ clinical care management data to identify trends, develop actions plans, program modication for improved outcomes.
• Participates in special projects or other duties as assigned.