Two Chicks With A Side Hustle

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.