May perform telephonic and/or face-to-face assessments Engage patient, family, and caregivers telephonically to assure that a well-coordinated action plan is established and continually assess health status Provide member education to assist with self-management goals; disease management or acute condition and provide indicated contingency plan Identify patient needs, close health care gaps, develop action plan and prioritize goals Utilizing evidenced-based practice, develop interventions while considering member barriers independently Provide patients with "welcome home" calls to ensure that discharged patients’ receive the necessary services and resources according to transition plan Conducts a transition discharge assessment onsite and/or telephonically to identify member needs at time of transition to a lower level of care Independently serves as the clinical liaison with hospital, clinical and administrative staff as well as performs a review for clinical authorizations for inpatient care utilizing evidenced-based criteria within our documentation system for discharge planning and/or next site of care needs In partnership with care team triad, make referrals to community sources and programs identified for patients Utilize motivational interviewing techniques to understand cause and effect, gather or review health history for clinical symptoms, and determine health literacy Manages assessments regarding patient treatment plans and establish collaborative relationships with physician advisors, clients, patients, and providers Collaborates effectively with Interdisciplinary Care Team (IDCT) to establish an individualized transition plan and/or action plan for patients Independently confers with UM Medical Directors and/ or Market Medical Directors on a regular basis regarding inpatient cases and participates in departmental huddles Demonstrate knowledge of utilization management processes and current standards of care as a foundation for utilization review and transition planning activities Maintain in-depth knowledge of all company products and services as well as customer issues and needs through ongoing training and self-directed research Manage assigned caseload in an efficient and effective manner utilizing time management skills Enters timely and accurate documentation into designated care management applications to comply with documentation requirements and achieve audit scores of 95% or better on a monthly basis Maintain current licensure to work in state of employment and maintain hospital credentialing as indicated Performs all other related duties as assigned