Available on provided telephonic platform, both taking and placing calls to coordinate care for members between facilities, hospitals, and Optum field colleagues Utilize EMR proficiently to provide acute care to members during overnight and weekend/ holiday hours Primary Care Delivery Deliver cost-effective, quality care to 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 encounter is documented appropriately to support the diagnosis at that visit The APC is responsible for ensuring that all quality elements are addressed and documented Utilizes practice guidelines and protocols established by HCC Must attend and complete all mandatory educational training requirements Care Coordination 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, HCC staff and other provider groups  Ability to meet shift scheduling requirements, and attendance expectations 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  Demonstrate initiative in achieving individual, team, and organizational goals and objectives Participate in HCC quality initiatives Availability to check Optum email intermittently for required trainings, communications, and monthly scheduling