Practices in accordance with the respective state laws and regulations governing the practice of advanced practice nursing or physician assistants Establishes and maintains effective relationships with patients, care givers, and/or their legal representatives, IDT members, PCPs, other collaborating physicians/providers, and facility staff when applicable Performs an initi

Conduct in home assessments including an evaluation of past medical history, review of systems, medication reconciliation, vital signs, and comprehensive physical exam Perform evidence based practice screenings including point of care testing (as appropriate) Identify diagnoses to be used in care management and active medical management in the furtherance of treatment For

Conduct in home assessments including an evaluation of past medical history, review of systems, medication reconciliation, vital signs, and comprehensive physical exam Perform evidence based practice screenings including point of care testing (as appropriate) Identify diagnoses to be used in care management and active medical management in the furtherance of treatment For

Conduct in home assessments including an evaluation of past medical history, review of systems, medication reconciliation, vital signs, and comprehensive physical exam Perform evidence based practice screenings including point of care testing (as appropriate) Identify diagnoses to be used in care management and active medical management in the furtherance of treatment For

Conduct in home assessments including an evaluation of past medical history, review of systems, medication reconciliation, vital signs, and comprehensive physical exam Perform evidence based practice screenings including point of care testing (as appropriate) Identify diagnoses to be used in care management and active medical management in the furtherance of treatment For

Conduct in home assessments including an evaluation of past medical history, review of systems, medication reconciliation, vital signs, and comprehensive physical exam Perform evidence based practice screenings including point of care testing (as appropriate) Identify diagnoses to be used in care management and active medical management in the furtherance of treatment For

Locate, outreach and engage members within the community that clinicians and care navigators have not been able to reach; create a positive experience and relationship with the member Assesses functional and social needs of members and collaborates to develop and implement solutions with the frequency established in the model of care Work collaboratively the multidiscipli

By serving as the link between patients and the appropriate health care personnel, the SICC is responsible for ensuring efficient, smooth, and prompt transitions of care Perform Skilled Nursing Facility (SNF) assessments on patients using clinical skills and utilizing CMS criteria upon admission to SNF and periodically through the patient stays Review targets for Length o

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 Me

Conduct comprehensive assessments Manage members through an acute medical situation or an exacerbation of a chronic condition, including testing, diagnostics, interventions Manage members during a short term sub acute rehabilitation episode Ensure accurate and complete documentation, including ICD 10 conditions Communicate and collaborate with the interdisciplinary care t

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 Me

Conduct in home assessments including an evaluation of past medical history, review of systems, medication reconciliation, vital signs, and comprehensive physical exam Perform evidence based practice screenings including point of care testing (as appropriate) Identify diagnoses to be used in care management and active medical management in the furtherance of treatment For

Conduct in home assessments including an evaluation of past medical history, review of systems, medication reconciliation, vital signs, and comprehensive physical exam Perform evidence based practice screenings including point of care testing (as appropriate) Identify diagnoses to be used in care management and active medical management in the furtherance of treatment For

Conduct comprehensive assessments Manage members through an acute medical situation or an exacerbation of a chronic condition, including testing, diagnostics, interventions Manage members during a short term sub acute rehabilitation episode Ensure accurate and complete documentation, including ICD 10 conditions Communicate and collaborate with the interdisciplinary care t

Conduct comprehensive assessments Manage members through an acute medical situation or an exacerbation of a chronic condition, including testing, diagnostics, interventions Manage members during a short term sub acute rehabilitation episode Ensure accurate and complete documentation, including ICD 10 conditions Communicate and collaborate with the interdisciplinary care t