Responsible for assisting in the successful implementation of the Home Discharge visit program and social work services.
Provides individuals assessment and care management to members who are at high risk for pre-admissions, re-admissions and for the members at the risk for complex hospitalizations and/or long term health management needs.
They will provide in-depth psychosocial assessment to members through home visits and develop care plan in collaboration with the post discharge visit program personnel and other contracted health care practitioners.
In addition, they will provide knowledge, expertise, resources that are specific to members as well as information and referrals to community resources and services; and benefits independent of product line
The goal of Post discharge visit Program is to establish early identification and focused care coordination of high risk members at risk for re-admissions and complications related to identify risk factors and to educate and facilitate appropriate services for the member.
They will collaborate closely with the other disciplines and programs to effectively manage members to assure that appropriate level-of-care is provided, to prevent member re-admissions and ensure that the member's medical, environmental and psychosocial needs are met.
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