The representative responds to member and provider inquiries regarding benefits, claims, and complaints within a call center environment. They are responsible for documenting all interactions, managing grievances, and processing requests for claim adjustments or disenrollment.
The RN Care Manager provides comprehensive case management by assessing the medical, social, psychological, physical, and spiritual needs of members. They develop, implement, and monitor individualized care plans in collaboration with primary care physicians, caregivers, and the interdisciplinary team.
The Social Work Care Manager provides telephonic support for members' medical, psychosocial, and spiritual needs while developing person-centered service plans. They ensure continuity of care by collaborating with interdisciplinary teams and educating members on disease processes and preventative health.
The Transitional Care RN acts as a patient advocate by facilitating and coordinating the transition of patients to the next level of care. This role involves collaborating with facility discharge planners and case management staff through telephonic outreach and in-person assessments.
