Performs and/or oversees the holistic assessment and develops a community based plan of care.
February 01, 2020
Works in collaboration with Quality Improvement to establish documentation standards, recommended workflows, and policies and procedures for clinical staff.
March 11, 2020
Assists in development and design of action plans to support compliance with measures indicators and provides support and educational resources to departments and services relative to core measures quality assessment and improvement processes.
March 18, 2020
Provide on-site, community, and telephonic outreach to patients, providers, and community stakeholders assisting with identification of treatment history, diagnoses and patient care components both internally and externally to ensure that services provided are sensitive to the needs of individual patients and take into account ethnic and cultural backgrounds.
March 29, 2020
Monitor the status and the impact of the health plan for each client and responsible for altering the care plan as deemed appropriate by the dynamic, ever changing member/client needs.
May 15, 2020
Develop and implement population health management strategies to improve health outcomes, the patient experience, and healthcare value including risk stratification methods, data management and tracking, case management across the care continuum, development of care models for skilled nursing facilities, and feedback to physicians on outcomes and utilization.
June 03, 2020
Demonstrated ability to work productively and effectively with a complex environment, handle multiple priorities and deal with stresses associated with dealing with vulnerable people who have complex health and social needs desired.
June 22, 2020