You Will Focus On:

• Works across the continuum of care in order to facilitate and promote high quality, cost effective outcomes, focused on the whole patient orientation and self management decision support and aims to minimize any fragmentation of health care delivery.
• Acts as the liaison between the member, the member’s support network, treating physician(s), and ancillary providers utilizing a multi-disciplinary approach to assess, identify, plan, health goal setting and measure optimal clinical outcomes.
• Employs behavior change/motivational interviewing skills to assess readiness, health goal setting short and/or long term needs, engage member’s plans for change following standard policy and procedures, clinical guidelines and national evidenced based criteria.
• Works collaboratively with the Care Management team, Health Care Analytics, Performance Improvement departments, Health Plans and Brown & Toland physicians and their offices to identify individuals who require care management wellness and prevention services.
• Masters the use of Brown & Toland e-tools to identify and target needs of risk populations.
• Develops of patient outreach activities such as mailings, reports as well as physicians level quality performance reports.
• Support development, implementation and evaluation of any Brown & Toland programs and activities to improve optimal health outcomes.
• Acts as patient advocate responding to and working to resolve patient concerns or barriers.
• Assist in the development, implementation and evaluation of standards of care, policies, procedures, medical review criteria and protocols to improve care management throughout the delivery system and across the care continuum.
• Serve as a resource to members and B&T physicians. Maintains up to date information on community resources, health coaching literature or recommended screenings and community based programs.
• Communicate timely with primary care providers, specialists and any community affiliates to ensure continuum of care.

The Skills And Experience You Bring:

• LCSW in California
• EMR Experience (Epic is preferred)
• 3+ Palliative Care as an LCSW
• Ability to communicate well; excellent written skill; ability to identify issues readily and resolve problems; ability to maintain a high volume workload and changing priorities; work well under pressure.

You Share Our Mission & Values:

• You are passionate about improving the healthcare experience and want to be part of the Altais mission.
• You are bold and curious- willing to take risks, try new things and be creative.
• You take pride in your work and are accountable for the quality of everything you do, holding yourself and others to a high standard.
• You are compassionate and are known as someone who demonstrates emotional intelligence, considers others when making decisions and always tries to do the right thing.
• You co-create, knowing that we can be better as a team than individuals. You work well with others, collaborating and valuing diversity of thought and perspective.
• You build trust with your colleagues and customers by demonstrating that you are someone who values honesty and transparency.