• The Case Management Coordinator utilizes critical thinking and judgment to collaborate and inform the case management process. • Facilitates appropriate healthcare outcomes for members by providing assistance with appointment scheduling, identifying and assisting with accessing benefits and education for members through the use of care management tools and resources. • Conducts comprehensive evaluation of member’s needs/eligibility and recommends an approach to case resolution and/or meeting needs by evaluating member’s benefit plan and available internal and external programs/services. • Identifies high risk factors and service needs that may impact member outcomes and care planning components with appropriate referral to clinical case management or crisis intervention as appropriate. • Coordinates and implements assigned care plan activities and monitors care plan progress. • Using holistic approach consults with case managers, supervisors, Medical Directors and/or other health programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary review in order to achieve optimal outcomes. • Identifies and escalates quality of care issues through established channels. • Utilizes negotiation skills to secure appropriate options and services necessary to meet the member’s benefits and/or healthcare needs. • Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promote lifestyle/behavior changes to achieve optimum level of health. • Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices. • Engages with colleagues in ongoing team meetings and offers peer mentoring/training. • Helps member actively and knowledgably participate with their provider in healthcare decision-making. • Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.

• Conducts comprehensive evaluation of member’s needs/eligibility • Recommends an approach to case resolution • Identifies high risk factors and service needs • Coordinates and implements assigned care plan activities • Monitors care plan progress • Consults with case managers, supervisors, Medical Directors and/or other health programs • Identifies and escalates quality of care issues • Utilizes negotiation skills to secure appropriate options and services • Provides coaching, information and support to empower the member • Engages with colleagues in ongoing team meetings

• Provides active care management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans, to include member goals • Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions • Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits • Provides telephonic support for members with chronic conditions, high-risk pregnancy or other at-risk conditions that consist of intensive assessment/evaluation of condition, at-risk education based on members’ identified needs, provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to change assessment to elicit behavior change and increase member program engagement • Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans • May identify, initiate, and participate in on-site reviews • Serves as member advocate through continued communication and education • Promotes enrollment in care management programs and/or health and disease management programs • Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members • Performs medical or behavioral review/authorization process • Ensures coverage for appropriate services within benefit and medical necessity guidelines • Utilizes allocated resources to back up review determinations • Identifies and makes referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of care Referrals, etc.) • Participates in data collection/input into system for clinical information flow and proper claims adjudication • Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, which may include but is not limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal) • Maintains current knowledge of contracts and network status of all service providers and applies appropriately • Assists with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services

• Conduct the annual Health Risk Survey to support needs identification for the member’s Individual Plan of Care. • Inform the assigned care manager of newly identified health/safety risks or service needs. • Complete care coordination activities delegated by the care manager within an established timeframe. • Inform the assigned care manager and/or associate manager of any identified quality of care issues. • Passionately support the member’s care coordination needs and drive solutions to address those needs. • Use problem-solving skills to find alternative contact information for members who are unreachable by care management. • Employ motivational interviewing techniques to maximize member engagement and promote lifestyle changes for optimal health. • Adhere to case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies.