Nurse Case Management Senior Analyst

Worker must feel comfortable taking a high volume of inbound calls and making outbound calls in between. If they do not have much experience with electronic charting, this is NOT the position for them! Must be able to document while talking on the phone so typing fast is essential.

Perform Health Risk Assessments (HRA) on Special Needs Plan (SNP) customers.

Triage customers with an HRA to decide if they need further follow up. Refer high risk customers to case management in the local market Refer customers with Behavioral Health needs to the Enterprise Behavioral Health team

Outreach to all customers with an HRA completion to develop a higher level care plan, if needed.

Identify and address customer gaps in care, which may include primary care physician and specialist appointment scheduling.

Provide clinical assessments, health education, and community resources to customers, as needed.

Identify and develop community resources for customers to include: paying for medications, food, utilities and housing. Local referrals for tax and legal aid.

Disease management education for chronic illnesses to include: diabetes, hypertension, CHF, COPD and others.

Initiate contact with customer/caregiver/family, primary care physician, and health care providers/suppliers as needed.

Develop customers individualized plan of care, as well as communicate the plan of care to the customer. Conduct Interdisciplinary care team activities with the customer's complete health team, when necessary

Document all encounters with the customers, practitioners and providers. Handle crisis call