The coordinator reviews and evaluates medical or behavioral eligibility against benefits and clinical criteria using clinical expertise and administrative policies. They assess, plan, coordinate, monitor, and evaluate medical necessity and care plan compliance to support members managing their health.

The Care Coordinator performs various medical necessity reviews, including inpatient, concurrent, prior authorization, and retrospective reviews, to ensure compliance with established criteria and protocols. This role involves partnering with Medical Directors and other departments to assess the medical necessity of services and ensure cost-effective care across all lines of business.

The RN is responsible for determining the appropriate Care Management program for referred members by utilizing department guidelines and established criteria to assign them to the correct care management component. Primary duties involve using the nursing process to meet health needs, educating members about providers, and collaborating with medical and care management associates to identify issues and assign resources.

The Care Coach manages a caseload, develops and modifies Individual Care Plans, and provides specialized support focusing on addressing health-related social needs and psychosocial support for members. This involves assessing needs, ensuring appropriate service settings, and collaborating with internal and external agencies to access necessary social, housing, and educational services.