- Maintain ongoing caseload of individuals through the utilization of evidence based approaches to promote engagement and achievement of health goals
- Use relationship-based strategies to support members with social support navigation, understanding that many may have lived personal experiences causing them to be initially hesitant or distrusting of the health care system
- Conducts periodic telephonic and SMS outreach to ensure timely follow-up to members
- Work with members to identify health/wellness goals and incorporate goals into Health Action Plan/Shared Care Plan
- Supports nurse care manager, behavioral health care manager, nurse practitioner and Community Engagement Specialist with delegated tasks
- Collaborates on care issues with Enhanced Care Management team by participating in systematic case reviews and consulting with nurse care manager, behavioral health care manager, and nurse practitioner before taking clinical actions
- Consistently meet monthly encounter metrics to ensure compliance with health plan regulations
- Identify and break down barriers ensuring individuals’ continuation with the program
- Assists individuals in securing connection to community supports by scheduling appointments, managing referrals, and ensuring timely follow-ups
- Coordinate physical care management appointments through collaboration with external and internal providers
- Utilize external and internal online platforms to collaborate with team members and carry out daily tasks
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