Reviews data reports received from Care Impact, VH and CMARC referrals from providers and community members to identify children birth to five who would benefit from care management based on the Standardized Plan.
Evaluates priority risk factors identified by claims data analysis, hospital records and referrals, then contact the family of the child and evaluate for needs based on program guidelines.
Initiates Comprehensive Health Assessments on all clients determined to be at risk.
Establishes processes to support care management based upon risk stratification guidelines outlined in Standardized Plan.
Complete LSP and SWYC face to face as appropriate.
Engages clients in care management services by making timely contacts as outlined in the Standardized Plan based on needs and identified risks.
Develops and documents patient–centered care plans by addressing barriers and determining interventions based on client needs.
Refers clients to local community resources to meet the specific needs and follows-up to evaluate outcomes.
Supports Public Health in preparedness exercises.
Performs other related duties as assigned.