Acts as an advocate for the patient Engages and collaborates with patient/caregiver and providers to develop an individualized Care Plan that addresses disease management, health promotion, and patient-centered goals Monitors patient progress against Care Plan goals with an emphasis on patient care needs during times of transition in care setting and changes in health status Identifies barriers to achieving Care Plan goals and collaborates with patient/caregiver as well as IDT to overcome barriers to success Understands and adheres to regulatory timeframes and standards required by National Committee for Quality Assurance (NCQA) within a Delegated Case Management market and Dual & Chronic Special Needs Plans (SNP) Provides disease management, health promotion and prevention education to patients/caregivers and/or family patients to manage disease progression and encourage proper medical testing, so patient can remain as independent as possible Completes initial and ongoing patient assessment, using information gathered from patient/caregiver/family, providers, Home-based Medical Care EMR, and available medical records Manages and coordinates care and services within an Interdisciplinary Team Manages incoming clinical calls to ensure patients’ medical concerns are addressed by the care team in a timely manner Participates in and documents advance directive conversations with patient/caregiver and/or family, and collaborates to reconcile patient/caregiver goals with the current clinical status Coordinates care needs across the continuum of care and is the point of contact for patient/caregiver and clinicians Leads daily IDT Huddle Actively participates in Home-based Medical Care meetings and education sessions Acts as liaison between providers, nursing facilities, hospitals and program staff, including making recommendations about care alternatives Facilitates/coordinates admission to a recommended level of care on a temporary or permanent basis Promotes patient safety. Reviews or initiates a home safety, functional assessment, and/or falls risk assessment with home-based providers to determine need for adaptive equipment. Assists with acquisition of assistive equipment, as recommended Monitors patient during admissions and provides nursing/assisted living facility and provider training on Home-based Medical Care program philosophy and approach to patient care Supports patients during transitions of care through assessment, coordination of care, education of the plan of care and evaluation of the effectiveness of the plan Identifies and reports any potential quality-of-care issues to Clinical Supervisor/HSD, so a plan of improvement can be developed and implemented, as needed At times, the NCM may visit a patient in their home for education or assessment, Market/State dependent Maintains HIPAA compliance at all times