Essential Job Functions:
- Achievement of Clinical Objectives
- Reviews status of participant’s preventive health exams as defined by the disease-specific Standards of Care guidelines. Initiate appropriate interventions for member.
- Contacts participant by telephone as needed for information sharing, assessment, intervention, and behavioral goal setting.
- Identifies educational needs of participant and facilitate educational opportunities (i.e., mails patient education materials; refer to health plan if appropriate).
- Reviews participant’s functional status, formal and informal family support system, determining participant’s desired outcome of care and needs for participant education.
- Develops and facilitates implementation of a care plan addressing the total healthcare needs of the participants. Specific focus and resources will be directed to the specific problem resulting in the appropriate stratification level.
- Identifies participant barriers to accessing health care services. Coordinates with Provider Service Managers and/or other members of the disease management program team when available to remove system barriers.
- Functions as integral part of the multi-disciplinary team. Facilitates communication exchange with primary managing physician and other providers, health plan, and the disease management program team.