General Summary:

Responsible for case management activities for Health Alliance Plan (HAP) dual eligible members using a multi-disciplinary, patient-centered approach. Provides bio/psycho/social assessments, develops an individualized care plan, implements case management interventions, facilitates an interdisciplinary care team, coordinates care, monitors outcomes and evaluates the delivery of quality, cost effective health care services across the continuum of care. Oversees the day-to-day operations of member-centered comprehensive care coordination for members enrolled in dual government programs, while ensuring adherence to all regulatory requirements. 

 Principal Duties and Responsibilities:

• Facilitate access of healthcare services for dual eligible members and identify plans for strategies to reduce avoidable utilization and encourages appropriate resource use. Works with physicians and other health care providers to adjust plans of care as required.
• Provide liaison services to dual eligible members and providers. Represents HAP in the community to peers, physicians, and providers as a member advocate for the HAP dual eligible population.
• Conducts assessments of member’s needs including current health conditions, preventive screenings, medical service utilization, cognitive/functional status, social determinant of health concerns, including food insecurity, transportation and housing, and behavioral health concerns including depression and substance use screening.
• Collaborates with external resources/agencies and post-acute care health teams to optimize the members outcomes and improve the care experience when transitioning to the next level of care or home.
• Familiarity, comprehension, and compliance with the Dual Eligible Special Need Population Model of Care (MOC).
• Attend and actively participate in the dual eligible member advisory committee, offering oversight and resolution as necessary based on feedback received.
• Develop, implement, monitor, and modify a plan of care through an interdisciplinary and collaborative team process, in conjunction with the member, the caregivers and the healthcare team.
• Maintain a level of competency and knowledge related to case management, disease processes and acute illnesses to assist with care coordination.
• Advocates for the member/family/caregiver throughout episodes of care.
• Maintains availability to member/family/caregiver as a resource to facilitate communication among the multidisciplinary team and to monitor services rendered. Remains involved throughout the member’s enrollment in the dual eligible plan.
• Develops and maintains relationships with internal and external resources to ensure member needs are met. Identifies the need for and coordinates mental health/substance abuse interventions within HAP (or designee).
• Uses independent, clinical judgment and discretion to address, resolve, and process problems impeding the diagnostic or treatment process. Proactively identifies and resolves delays and obstacles.
• Facilitates referrals for additional medical and ancillary services, including home healthcare, infusion therapy, palliative care, hospice, inpatient extended care facilities, and medical equipment and supplies, as needed.
• Participate in the development of cost savings opportunities through the identification of quality management, case management, and multi-disciplinary processes.
• Refer cases to Physician Advisors and/or Plan Medical Directors when appropriate, where quality issues are identified .
• Coordinate and assist in the development of innovative alternative care delivery mechanisms to meet special needs of members.
• Maintain electronic medical records including professional, clinical documentation to ensure continuity of care and compliance to regulatory requirements (e.g., HIPAA, D-SNP Model of Care, CMS guidelines).