- Complete telephonic and in-person monitoring visits with participants, caregivers, or providers to gather information to assess need for services for person centered care plan development
- Coordination and authorization of referrals
- Ensure continuity of care and uninterrupted service delivery and identify gaps in plans of care
- Assist in coordinating the development of informal or voluntary services to integrate into the participants person centered service/care plan
- Work with physicians, care managers, discharge teams, and other parties to ensure optimal discharge plan, care plan, and coordination of short and long term care services
- Aid participants with submitting appeals and resolving complaints and concerns