• Develops a proactive plan of care to address identified issues • Uses clinical tools and information/data review to conduct an evaluation of member's needs and benefits • Applies clinical judgment for strategies to reduce risk factors and barriers • Conducts assessments considering information from various sources • Uses a holistic approach to assess the need for referrals to clinical resources • Collaborates with healthcare supervisors and stakeholders • Utilizes case management processes in compliance with regulatory and company policies • Utilizes motivational interviewing skills for maximum member engagement • Interacts with members/clients telephonically or in-person • May meet with members/clients in various settings for ongoing case management services

• Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. • Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. • Services and strategies, policies and programs are comprised of network management, clinical coverage, and policies.

• Develops a proactive plan of care to address identified issues to enhance the short and long-term outcomes as well as opportunities to enhance a member’s overall wellness. • Uses clinical tools and information/data review to conduct an evaluation of member's needs and benefits. • Applies clinical judgment to incorporate strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning. • Conducts assessments that consider information from various sources, such as claims, to address all conditions including co-morbid and multiple diagnoses that impact functionality. • Uses a holistic approach to assess the need for a referral to clinical resources and other interdisciplinary team members. • Collaborates with supervisor and other key stakeholders in the member’s healthcare in overcoming barriers in meeting goals and objectives, presents cases at interdisciplinary case conferences • Utilizes case management processes in compliance with regulatory and company policies and procedures. • Utilizes motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.

• negotiates, executes, conducts high level review and analysis • dispute resolution and/or settlement negotiations of contracts • maintain and enhance provider networks • meeting and exceeding accessibility, quality and financial goals