Provide support to participants/patients/members in case and disease management programs to meet their treatment/care plan goals in coordination with case managers where appropriate.
Support members in navigating and connecting to clinical and community resources. Assist patients to connect to health screening programs and resources.
Document care coordination, care gaps, and discharge planning needs and activities in a timely manner in care management systems independently and in coordination with case managers and other team members.
Assist clinical staff in identifying and providing outreach, orientation, and baseline assessment services to participants/patients/members that may benefit from navigation services.
Establish and maintain effective, ongoing relationships by facilitating communication and coordination with /participants/patients/members, their caregivers and PCPs/Providers as well as other identified resources to which the patient was referred, based on each member's continued needs.
Provide one to one guidance, support, education, coordination of care and other assistance to participant/patient/member and/or their family members, as they move through the healthcare continuum.
Participate in case conferences and meetings with the CM team and medical directors in order to support effective care coordination.
Educate and answer inquiries from participants/patients/members and/or their family members about benefits, services, eligibility and referrals with a positive and professional approach, promoting participant/patient/member satisfaction and retention.
Develop/update and support any member centric education materials and mailings when appropriate.
Identify and provide appropriate resources and community referrals for participants/patients/members, facilitating access to appropriate support services, including medical and social resources to address presenting issues and assist in the removal of barriers.
Assist members in getting appointments and access to appropriate health care and community program services. Initiate follow-up to confirm and coordinate additional needs of the member to support coordination of care across care settings and needs.
Participate in Interdisciplinary collaborative with CM team, internal departments and external partners as well as community resources to ensure most appropriate level of care and optimal outcomes.
Perform related duties as assigned.
Brown & Toland