Description: Job Summary:
Completes face to face Health Functional Assessments (HFA) to identified members, as directed by DHS guidelines both in the community and health care institutional facilities. Develops a client focused QI service plan collaboratively with primary care physician (PCP) and other decision makers. Assists with access to medical care and services. Coordinates all home community based services, supplies and equipment, for adults and children needing Long Term Support and Services (LTSS) to live independently in the community.
Essential Responsibilities:

• Provides care management (CM) and care coordination to both QI community and institutional members. Completes the Face to Face Health Functional Assessment and Service plan. Care management is provided across the continuum of health care needs - the community, hospital, skilled nursing facility or institution.


• Maintains required documentation using KPHC el...