PRIMARY FUNCTION

Supports the daily operations of the Virtual Hub by providing select program interventions in accordance with established care management program guidelines for identified at risk members under the direction of a member of the clinical team. Provide administrative to a clinical team responsible for a defined population of members/beneficiaries.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

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• Performs in a call center environment appropriately processing or triaging calls from members, caregivers, providers, internal and external customers
• Handles in/outbound calls and transactions directly supporting clinical staff and assigned teams in accordance with metric and performance requirements
• Assists in the enrollment of members in a care management program according to established program guidelines
• Creates updates, maintains and/or closes tasks as assigned within process guidelines. Routes case to appropriate Care Coordinator based on established guidelines
• Collaborates with the members, care givers, physicians, staff, and other health care professionals across the continuum to provide care coordination at the direction of the Care Coordinator including, but not limited to: implementing program interventions, documenting activities, assisting providers in obtaining authorizations, making follow up phone calls and sending out educational materials and letters
• Assists members and caregivers with problem resolutions and strategies to reduce barriers to care and increase health care compliance
• Identifies problems or gaps in community resources that impact outcomes, care or utilization of services and communicates problems or gaps to the Care Coordinator
• Identifies members with Care Gaps/HEDIS related health conditions and assists them in accessing care through scheduling appointments and referral to community resources
• Reinforces with members the prescribed treatment plan including attainment of goals and identification of barriers to success