Our Care Planning Unit (CPU) is primarily responsible for developing and ensuring adherence to high quality, member-centric care plans through timely execution of community-based assessments for members and ongoing tracking and monitoring.
The Care Planner conducts timely, high quality, accurate in-person assessments. This individual leverages the Minimum Data Set (MDS) assessment and develops and documents person-centered care plan using data collected during the assessment process. This individual works collaboratively with other members of the Care Planning Unit and staff in other departments as needed to support timely interventions designed to improve outcomes for members.
Conducts in-person assessment visits. Documents templated summary of visit highlights; documents MDS and develops initial person-centered Care Plan including current Service Plan within 48 hours of visit.
Communicates any time-sensitive concerns to Regional RN Supervisor and/or NP during or immediately following visit.
• Reviews members with NP and BH Specialist staff in weekly Stratification meetings to validate Care Model assignment and facilitate warm hand off to Care Partner
• Ensures immediate referral to any time-sensitive services such as Behavioral Health, Long Term Services and Supports or Physical Therapy.
• Manages assessment activities through calendar and tracks status of completion
• Participates in assessing and improving quality within the scope of responsibilities and throughout the organization
• Participates in activities and education to maintain and advance clinical competencies
• Seeks to maintain a constructive work environment and maintains effective communication with other employees and managers
• Maintains confidentiality of patient and employee information
• Complies with organization’s policy and procedures
Demonstrate integrity by working with passion, commitment, and honesty, acting in the best interests of colleagues and members. Approach work in a collaborating and caring manner interacting with insight, sincerity, and compassion. Demonstrate accountability by delivering on commitments, owning mistakes as well as successes, and contributing to an empowering environment where the focus is on solving problems and learning from errors. Recognize and respect diversity in all forms. Strive for excellence in the fulfillment of our mission through quality, innovation, and continuous learning. Demonstrate initiative, flexibility, and openness to change. Represent us and its clinical affiliates with professionalism. Keep current and proficient with necessary skills and knowledge. Self-identify training and development needs relevant to work area and responsibilities. Adhere to all applicable compliance requirements including but not limited to:
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