Ensures quality care by using advanced knowledge to review patient assessments, care, and interventions for completeness and accuracy, prioritizing the patient experience during care transitions, documenting treatment plan progress, contributing updates in multidisciplinary clinical meetings, and coordinating care needs (e.g., coordinating transfers, planning discharges, making community service referrals, reviewing and/or obtaining authorizations) across the continuum of care. Coordinates patient care by collaborating with treating clinicians to review and improve treatment plans, advises and/or coordinates services to enhance care coordination, makes referral recommendations, develops and maintains case management policies, and solves issues related to treatment plans and follow-up appointments. Ensures compliance with policies to promote patient care and avoid liability, solves compliance failures, applies standards and regulations in interactions with patients, physicians, contact providers, medical staff, and outside agencies, and leads efforts to maintain survey readiness and regulatory compliance in contracted facilities and/or medical centers. Collaborates with stakeholders to facilitate care by building relationships with external providers and medical staff, solving patient treatment issues, ensuring contract compliance, and serving as a liaison on contracting and referral processes. Manages patient data and records by compiling and reporting information (e.g., length of stay, services provided, cost), facilitating interventions, conducting quality management studies and/or audits, and collaborating with stakeholders to improve practices.

• Promotes learning in others by proactively providing and/or developing information, resources, advice, and expertise with coworkers and members; builds relationships with cross-functional/external stakeholders and customers. Listens to, seeks, and addresses performance feedback; proactively provides actionable feedback to others and to managers. Pursues self-development; creates and executes plans to capitalize on strengths and develop weaknesses; leads by influencing others through technical explanations and examples and provides options and recommendations. Adopts new responsibilities; adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; champions change and helps others adapt to new tasks and processes. Facilitates team collaboration to support a business outcome.


• Completes work assignments autonomously and supports business-specific projects by applying expertise in subject area and business knowledge to generate creative solutions; encourages team members to adapt to and follow all procedures and policies. Collaborates cross-functionally and/or externally to achieve effective business decisions; provides recommendations and solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Supports the development of work plans to meet business priorities and deadlines; identifies resources to accomplish priorities and deadlines. Identifies, speaks up, and capitalizes on improvement opportunities across teams; uses influence to guide others and engages stakeholders to achieve appropriate solutions.


• Ensures quality of care by: using advanced knowledge to review moderately complex patient assessments, care, and interventions for completeness and accuracy; prioritizing patient experience during internal and external care transitions by proactively anticipating and identifying barriers; documenting the progression of treatment plans and conducting moderately complex chart reviews; contributing critical updates during multi-disciplinary clinical consultation meetings to discuss patient treatment; and coordinating patient care needs (e.g., coordinating transfers, planning discharges, making community service referrals, reviewing and/or obtaining authorizations) as they move across the continuum of care.


• Manages patient data and records by: compiling and reporting patient information and data (e.g., length of stay, services provided, cost) and facilitating interventions as necessary; and conducting quality management studies and/or audits through data collection, data input, and report development and collaborating with stakeholders to improve future practices.


• Coordinates the care of a moderate caseload of patients by: collaborating with treating clinician to review and ensure quality of patient treatment plans; advising, guiding, and/or coordinating services to improve care coordination based on quality principles; using advanced knowledge to recommend patient referrals for moderately complex cases; developing and maintaining case management policies and procedures to ensure optimal and appropriate member utilization and engagement of services; and solving problems concerning patient treatment plans and follow-up appointment documentation.


• Ensures member compliance with policies and procedures by: solving compliance failures to promote patient care and avoid liability concerns; applying local, state, and federal standards, regulations, credentialing organizations requirements, health plan benefits, policies, and procedures when working with patients, physicians, medical office staff, contact providers, and outside agencies; and leading efforts to support the survey readiness program at contracted facilities and/or medical centers to maintain compliance with regulatory standards.


• Collaborates with stakeholders to facilitate care by: cultivating relationships with external providers, medical center physicians, and/or other staff to solve patient treatment problems collaboratively and ensure contract compliance; and establishing relationships with outside contractors as well as serving as a liaison on contracting consultation including informing and advising on the organizations levels of care and referral process.