Assess members in the home or other face-to-face setting to assess the member’s wellbeing and develop an individual plan of care
Evaluate the home environment for safety, infection control, and community resource needs
Act as first level of support for the member to resolve patient related issues to ensure a positive member experience
Identify opportunities to manage the member-centric care plan, problems, barriers, interventions, and goals as appropriate
Partner with the Healthmap Interdisciplinary Care Team to collaborate on opportunities to improve member’s health outcomes
Serve as a resource to members and physicians while acting as a liaison between community resources, programs, and other relevant services
Educate Healthmap members on kidney health, related co-morbid conditions, and renal replacement therapy
Drive and shape clinical strategy to improve outcomes for members with chronic kidney disease
Document and maintain accurate member records that will identify all patient communication and plan. Maintain thorough documentation of all provider meetings/interactions and member interactions for consistency and coordination and compliance with regulatory standards Ensure company adherence with legal and regulatory requirements
Assist as a preceptor, mentor, and coach for new hire orientees
Demonstrate HIPAA understanding and complete confidentiality protocols
Follow all company-defined security/operational policies and procedures
Use multiple technical applications including Microsoft Word, Excel spreadsheets, electronic calendars, email, timekeeping and expense applications, and other software applications
Perform other duties as assigned