- Orient new members to the Belong Health DSNP program and educate on services.
- Conduct health risk assessments, reassessments, and clinical evaluations.
- Develop and implement an individual care plan (ICP).
- Identify members requiring intensive care management and coordinate services.
- Lead interdisciplinary care team meetings.
- Support transitions of care, including post-discharge outreach and medication reconciliation.
- Collaborate with providers, social workers, and community service organizations.
- Document care management activities in accordance with procedures.
- Utilize care management technology platforms to prioritize interventions.
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