Primary Care Delivery Deliver cost-effective, quality care to assigned members   Manage both medical and behavioral, chronic and acute conditions effectively, and in collaboration with a physician or specialty provider  Perform comprehensive assessments and document findings in a concise/comprehensive manner that is compliant with documentation requirements and Center for Medicare and Medicaid Services (CMS) regulations  Responsible for ensuring that all diagnoses are ICD10, coded accurately, and documented appropriately to support the diagnosis at that visit  The APC is responsible for ensuring that all quality elements are addressed and documented  The APC will do an initial medication review, annual medication review and a post-hospitalization medication reconciliation  Facilitate agreement and implementation of the member’s plan of care by engaging the facility staff, families/responsible parties, primary and specialty care physicians  Evaluate the effectiveness, necessity and efficiency of the plan, making revisions as needed  Utilizes practice guidelines and protocols established by CCM  Must attend and complete all mandatory educational and LearnSource training requirements  Travel between care sites mandatory  Care Coordination Understand the Payer/Plan benefits, CCM associate policies, procedures and articulate them effectively to providers, members and key decision-makers  Assess the medical necessity/effectiveness of ancillary services to determine the appropriate initiation of benefit events and communicate the process to providers and appropriate team members  Coordinate care as members transition through different levels of care and care settings  Monitor the needs of members and families while facilitating any adjustments to the plan of care as situations and conditions change  Review orders and interventions for appropriateness and response to treatment to identify most effective plan of care that aligns with the member’s needs and wishes  Evaluate plan of care for cost effectiveness while meeting the needs of members, families and providers to decreases high costs, poor outcomes and unnecessary hospitalizations  Program Enhancement Expected Behaviors Regular and effective communication with internal and external parties including physicians, members, key decision-makers, nursing facilities, CCM staff and other provider groups  Actively promote the CCM program in assigned facilities by partnering with key stakeholders (i e : internal sales function, provider relations, facility leader) to maintain and develop membership growth  Exhibit original thinking and creativity in the development of new and improved methods and approaches to concerns/issues  Function independently and responsibly with minimal need for supervision  Ability to enter available hours into web-based application, at least one month prior to available work time  Demonstrate initiative in achieving individual, team, and organizational goals and objectives  Participate in CCM quality initiatives     Availability to check Optum email intermittently for required trainings, communications, and monthly scheduling