Manage assigned member caseload telephonically Complete home engagement visits, when telephonic outreach attempts (3), are unsuccessful. Create a positive experience and relationship with the member Keep the member out of the hospital by supporting regular visits to their primary physician Keep member actively engaged with their primary physician Support the member to ens

Facilitate, oversee and monitor on going business processes to support HEDIS data reporting Monitor compliance against relevant process requirements (e.g., turnaround time, accuracy) Evaluate processes and outcomes against benchmarks and metrics and identify potential business impacts of current state Ensure all business requirements are met Demonstrate understanding of r

Perform telephonic customer outreach to improve health quality outcomes in collaboration with clinical pharmacists Provide additional telephonic engagement with providers and pharmacies Assess and interpret customer needs and requirements, triaging to a clinical pharmacist when appropriate Document and track member engagement You'll be rewarded and recognized for your per

Maintain detailed knowledge of State and Federal insurance programs and effectively utilize such programs to insure all eligible are enrolled in appropriate MassHealth programs Maintain detailed knowledge of MassHealth and attend all required MassHealth training forum meetings Assist in eligibility determination and completion of MassHealth applications Monitor, analyze a

Collect pertinent patient data (e.g., vital signs; complaints; medications and allergies; health screening information) in order to identify care needs Provide relevant medical services/care as directed by physicians (e.g., injections; procedures; treatments) Support and/or coordinate safe transportation of patients to and from medical appointments/facilities (e.g., drive

Demonstrate understanding of relevant organizations' operations, products, applications, strategies and processes to effectively support Quality Reporting Operations using relevant tools and applications Submission of the NCQA Health Plan Roadmap General Information, Appendix and Attestation Submission of the NCQA Healthcare Organization Questionnaire (HOQ) Complete admin

Perform initial and ongoing reviews pertaining to primary role (PA, ICM, DCM, PACM), appropriately applying clinical criteria (InterQual, policies, National and Local Coverage Determinations) for approval and sending to Medical Directors if review is necessary for determining an adverse determination Collaborate with Medical Directors, clinical peers and Health Plan partn

Assess, plan and implement care strategies that are individualized by patient 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 Com

Review and assess individual member clinical cases for high priority medication related opportunities and recommendations Provide written, consultative medication recommendations for interdisciplinary care management team members Directly contact medical providers over the telephone as needed to discuss pharmacy related consultative recommendations and provide benefit rel

Engage members face to face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic needs Develop and implement person centered care plans to address needs including management of chronic health conditions, health promotion and wellness, social determinants of health, medicati

Engage members face to face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic needs Develop and implement person centered care plans to address needs including management of chronic health conditions, health promotion and wellness, social determinants of health, medicati

Make outbound dialer and manual calls to members in regard to cancer support services Take inbound calls from members regarding cancer support services Determine if the consumers are eligible for a health program Schedule initial appointments with a nurse Must have accurate documentation Must meet monthly metrics Other duties as assigned You'll be rewarded and recognized

Support case and disease management teams to achieve optimal clinical outcomes for high risk populations Proficient in evidence based clinical guidelines and lead grand round clinical education sessions with nursing teams Primary functions include RN case manager support and consultation about high risk members and assisting in account management team presentations Be inv

Set strategy for experience improvement that supports FP member NPS and retention goals Establish a culture focused on our people obsessed with continual improvements to our members' experience Present strategy to senior management and measure against the strategy Identify, develop, and support the implementation of operational process changes & innovative solutions that

Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, at least 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