- Utilization case review and application of criteria to approve initial and continued inpatient services
- Identify patients in need of outreach efforts based on patient risk stratification or other defined criteria as well as defined disease management guidelines
- Work with CPHO team, patient’s Primary Care Physician and all other providers of the patients’ care to develop individualized care plans
- Facilitate communication with patients and care team, coordinate referrals, and promote optimal allocation of available resources
- Measure progress toward goals based on clinical judgment, review of patients’ self-monitoring tools and trends in clinical data
- Assess and monitor adherence to outreach and then problem-solve intrinsic and extrinsic barriers to effective patient self-management of chronic conditions
- Provide educational materials and resources to patient/family and their care providers
- Refer patients/families to self-management support programs as needed and communicate with care providers to ensure safe and effective care management.
- Analyze clinical data to track patient outcomes to determine improvement
- Triage patient phone calls for acute patient issues and counsel accordingly
- Oversight and management of population health quality improvement studies to reach established targets
- Interface with Commercial and Government entities on care coordination, HEDIS and other QI activities
- Report to UM/QM Committee on progress toward goals and make recommendations for improvement
- Other duties as assigned
- Minimum qualifications must be health plan requirements, including but not limited to licensure/certification, as applicable
Required
Required
Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights (https://www.eeoc.gov/poster) notice from the Department of Labor.
