Prioritizes patient care needs upon initial visit and addresses emerging issues Meets with patients, patients' family and caregivers as needed to discuss care and treatment plan Identifies and assists with the follow-up of high-risk patients in acute care settings, skilled nursing facilities, custodial and ambulatory settings Consults with physician and other team members to ensure that care plan is successfully implemented Coordinates treatment plans with the care team and triages interventions appropriate to the skill set of the team members. Uses protocols and pathways in line with established disease management and care management programs in order to optimize clinical outcomes and minimize unnecessary institutional care Monitors and coaches patients using techniques of motivational interviewing and behavioral change to maximize self-management Oversees provisions for discharge from facilities including follow-up appointments, home health, social services, transportation, etc. in order to maintain continuity of care Works in coordination with the care team and demonstrates accountability with patient management and outcome Discusses Durable Power of Attorney (DPOA) and advanced directive status with patient and PCP when applicable Maintains effective communication with the physicians, hospitalists, extended care facilities, patients, and families Provides accurate information to patients and families regarding resources available to them through health plan benefits, community resources, and referrals Participates actively in Monthly Care Management Department meetings and daily huddles Documents pertinent patient information and Care Management Plan in Electronic Health Record Coordinates care with central departments on assigned patient caseload, including, inpatient, long term care facilities, adult family homes, and home health agencies Demonstrates a thorough understanding of the cost consequences resulting from Care Management decisions through utilization reports and systems such as Health Plan Benefits, CM dashboards and reports Maintains concise and accurate documentation that supports effective and efficient management of care plans to decrease Emergency and hospital readmissions