<p>Responsible for providing care and services of selected member populations across the continuum of illness. Ensures effective utilization and monitors health care resources. Manages the interdisciplinary team to achieve optimal clinical and resource outcomes. Works with the Supervisor/Manager of Case Management to assess, plan, implement, coordinate, monitor and evaluate services and outcomes to maximize the health of the patient.</p> <p>Principal Accountabilities:</p> <ol> <li> <p>Manages, coordinates, and facilitates the care delivered to patients through patient/family assessment, including SDOH and multidisciplinary collaboration.</p> </li><li> <p>Ensures daily chart review, utilization reviews, coordination of discharge planning activities and comprehensive clinical documentation in the electronic medical record.</p> </li><li> <p>Provides interdisciplinary patient care rounds, and identifies and works to resolve quality of care issues, barriers to the progression of care and discharge delays.</p> </li><li> <p>Formulates, coordinates and implements discharge plans and an efficient plan of care to ensure safe, timely and effective discharge plan.</p> </li><li> <p>Works with the interdisciplinary healthcare team to manage and assist the patient care plan.</p> </li><li> <p>Performs variance tracking, outcome analysis and identifies problems to assess the effectiveness of the clinical pathways.</p> </li><li> <p>Performs other related duties as assigned.</p> </li></ol>