Making outbound calls to assess members' current health status Identifying gaps or barriers in treatment plans Providing patient education to assist with self-management Interacting with Medical Directors on challenging cases Coordinating care for members Making referrals to outside sources Coordinating services as needed (home health, DME, etc.) Educating members on disease processes Encouraging members to make healthy lifestyle changes Documenting and tracking findings Utilizing Milliman criteria to determine if patients are in the correct hospital setting Making welcome home calls to ensure that discharged member receive the necessary services and resources