Complete integrated care plans to promote collaboration with physical health providers and system partners.
March 15, 2020
Supports an integrated care model tapping into appropriate resources both internally and external to the organization required.
April 05, 2020
Facilitate care coordination with external entities including behavioral and physical health providers, Targeted Case Management (TCM), Transitions, Integration and Partnerships (TIP) Unit, Housing providers, Courts and Probation, Child Welfare, and School District of Philadelphia.
April 12, 2020
Actively participates in planning and growth of program with relevant stakeholders as needed, to respond to evolving needs of MassHealth ACO and the complex care management program.
April 12, 2020
Provide daily oversight of an assigned panel of high-need candidates/members, delivering interventions designed to reduce unnecessary emergency department (ED)/emergency room (ER) and inpatient (IP) utilization, increase connection to primary care/behavioral health care, and demonstrate improved health outcomes for the served population.
May 16, 2020
Maintains collaborative, team relationships with peers, colleagues and affiliated establishments in order to effectively contribute to the organizational goals and to help foster a positive work environment.
June 03, 2020
Develops patient-centered care plans with the patient/caregiver, providing all information to the healthcare provider, and establishes appropriate timelines for achieving identified goals.
June 20, 2020