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Quest Care Transition Specialist

2 months ago

Honolulu, United States HMSA Full time
  1. Engagement, Assessment and Planning
    • Engages members with the Event Driven Care program (outreach and successful enrollment) in facilities and other settings using system generated alert, census data or other sources which identify that patient have been admitted in the hospital, or registered in the Emergency Department, and their relative risks for readmission.
    • Engages with facility and other health care team to collaboratively plan on post discharge needs including participation in the interdisciplinary team meeting, as needed.
    • Assess member's progress throughout hospital stay and post discharge. Conducts and documents an ongoing assessment of the member's health psych/social needs, including health literacy, social determinants of health and deficits that identifies high risks and red flags for readmission. Gathers clinical information which includes past medical history, medications, physical/psychosocial factors, cultural influences, evaluation of health care barriers to include available support systems, available benefits, community resources, financial, employment, housing, educational, transportation and health information as appropriate to develop and create an effective individualized care plan.
    • Utilizes clinical knowledge and experience to coordinate integrated care-plan in collaboration with facility multidisciplinary team, Primary Care Provider (PCP), specialists and other healthcare providers/vendors. Goals developed will be prioritized, action-oriented and time-specific to stabilize the complicated health care condition.
    • Executes the transition of care coordination and supports the review of service request with Medical Management for a medical necessity determination.
    • Determine the need for and conduct inter-disciplinary and/or family care conferences.
    • Conduct face to face visits to member's homes, facility, community settings or PCP office Conduct telephone encounters.
  2. Implementation / Evaluation
    • Analyze daily severity based on risk stratification and LACE score and determine proper course of action by making critical decisions and utilizing independent clinical judgment.
    • Proactively identifies member care needs, and develops and communicates an effective and individualized Plan of Care. Ensures member is progressing towards desired outcomes by monitoring care through ongoing assessments and/or member records. Identifies and provides educational and community resources, support groups, medication review, pharmacy program and financial assistance and alternative payers (COBRA, SSDI etc.). Assists with planning and coordination including out of state services, follow-up appointment with treating physician, and assists with self-management of serious or complex conditions.
    • Address critical issues, including coaching and guidance to promote better understanding of healthcare issues and ongoing care needs to promote stability of healthcare in the least restrictive environment.
    • Communicate with providers and other healthcare team and is responsible to develop and cultivate relationships to ensure positive work relationships.
    • Interacts with the member as needed and necessary via telephone and face-to-face visits and provides support until the member and/or their authorized representative can manage and maintain the health of the member.
    • Documents the necessary communication and follow up with the member, family, physicians, and other health care providers to ensure the member's progression in meeting the established care plan goals.
    • Evaluates the extent to which the established goals in the plan of care have been achieved.
    • Evaluate member and provider satisfaction and quality of care provided.
  3. Miscellaneous Support
    • Participates in meetings with Providers, Provider Office group leaders, facility administrators, internal partners and quality/utilization leaders to improve quality and effectiveness of services provided to members.
    • Responsible for completion of documentation.
    • Assists in claims inquiries and resolution.

  4. Performs all other miscellaneous responsibilities and duties as assigned or directed

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