Interwell Health

General

• Handle inbound calls in a high-volume environment supporting SLA objectives
• Field clinical referrals, consent forms, or general inquiries routed to our Member Support Inbox and/or SharePoint
• Provide high quality service and support to callers, ensuring their needs are met efficiently and effectively from start to finish.
• Display professionalism, compassion, empathy, and active listening to understand caller needs and offer suitable solutions
• Collaborate across departments with internal clinical and non-clinical colleagues to ensure seamless care and service delivery, influencing positive member outcomes.
• Works well with fellow team members and actively contributes to team goals.
• Opportunities to assist with various projects

Member Support Coordinator

Clinical Operations

• Provide leadership, coaching and development for all direct reports to maintain an engaged and productive workforce.
• Monitor, supervise and balance workflow of the interdisciplinary virtual clinical care team.
• Ensure adequate staffing levels and manage clinician schedules to meet patient demand and needs.
• Partner with managers to set, communicate, and monitor clinician performance goals, ensuring alignment with program objectives and quality standards.
• Provide ongoing coaching, constructive feedback, and performance support to clinicians, proactively addressing performance issues and identifying opportunities for improvement, growth, and professional development.
• Foster a collaborative and inclusive team environment among direct reports, practice partners, and internal stakeholders, where individual differences are valued and leveraged to achieve organizational goals.
• Identify opportunities for improving processes and workflows and collaborate with virtual clinical operations leadership and other cross-functional leads to implement changes that enhance efficiency, patient experience, and care quality; monitor the effectiveness of implemented changes and adjust as necessary.
• Conduct regular quality assurance reviews of recorded clinician calls to ensure optimal member experience and adherence to clinical standards; ensure patient interactions meet the highest standards of care and empathy.
• Assist with interviewing candidates and training of new hires.

Clinical Supervisor – Virtual Clinical Operations

• Collaborate with interdisciplinary team members, including nurses, dietitians, care coordinators, and others, to deliver comprehensive virtual care services to patients.
• Provide support for patients and families coping with life transitions, chronic illnesses, and other psychosocial challenges.
• Empowers patients and caregivers by providing ongoing education regarding psychosocial issues related to kidney disease and all available support services including but not limited to transition to dialysis, conservative care, and advance directives.
• Conduct virtual assessments to identify patients’ social, emotional, and financial needs, with a focus on social drivers of health.
• Develop and implement individualized care plans that address patients' needs, connecting them with relevant community resources such as housing assistance, food programs, financial aid services, etc.
• Manages referrals regarding patients at high risk of poor health outcomes, barriers to complete treatment recommendations, and/or with complex psychosocial barriers. Identifies root cause(s) of barrier(s), develops plan of intervention with an evidence-based approach, executes intervention, and monitors success of intervention. Re-evaluates interventions and plans as necessary.
• Provides supportive counseling services to patients as permitted within the scope of their clinical training and state license.
• Reports the discovery of unreported medical or social conditions or changes at home that may lead to adverse outcomes to the clinical team and ensures that these are referred to appropriate sources for attention.
• Advocate for patients by facilitating access to appropriate social services and supporting them through healthcare and social care navigation.
• Maintain thorough and timely documentation of all patient interactions, care plans, and interventions, ensuring compliance with company policies and regulatory requirements.

Licensed Master Social Worker, LMSW

• Make outbound calls to contact referred members of contracted clients to engage and educate members on the CKD program and its benefits.
• Effectively communicate how our services could benefit prospective patients, overcome patient objections, understand the elements of our value proposition, and adapt this to patients’ needs and concerns.
• Meet or exceed set goals, such as rate of enrollments/engagements, call volume, and documentation quality.
• Follow established company policies and procedures and apply acquired job skills to accomplish daily enrollment/ un-enrollment operations/processes.
• Determine eligibility for related plan members to ensure compliance, and obtain missing information for enrollment completion.

Enrollment Coordinator

• Collaborate with interdisciplinary team members, including nurses, social workers, care coordinators, and others, to deliver comprehensive virtual care services to patients.
• Conduct virtual nutritional assessments for patients with chronic kidney disease (CKD) and other co-morbid conditions, utilizing available patient information, self-reported health data, and dietary intake to inform care recommendations.
• Develop personalized, evidence-based nutrition care plans and calculate nutrition requirements tailored to the needs and preferences of patients at various CKD stages, often with other comorbid dietary considerations, focusing on dietary and lifestyle modifications that support holistic disease management.
• Educate patients and their caregivers on kidney-related dietary and lifestyle adjustments, including nutrition components related to kidney disease, co-morbidities, and conditions.
• Provide patients with resources and tools to manage their health conditions.
• Maintain thorough and timely documentation of all patient interactions, care plans, and interventions, ensuring compliance with company policies and regulatory requirements.
• Practice within the registered dietitian scope of practice and make necessary interdisciplinary referrals to nurses, social workers, care coordinators, and physicians when applicable.

Registered Dietitian

Analyst

• Responsible for leading development of a robust data infrastructure to support value-based healthcare insights generation and report development.
• Designs systems that ensure data integrity, enable self-service analytics and foster informed decision making.
• Collaborate with IT and analytics teams to ensure seamless integration of data sources into centralized infrastructure.
• Maintain and enhance data pipelines to ensure real-time access to reliable information.
• Develop analytical reports and dashboards to uncover trends and actionable insights in healthcare data.
• Create advanced data visualizations that enable stakeholders to understand complex data quickly and effectively.
• Validate and reconcile general reporting data across the organization.
• Create and maintain reporting in compliance with CMS and FHP policies, including ad-hoc reports and automation of manual reporting processes to enhance efficiency.
• Identify discrepancies and risks in data, conducting root cause analyses to recommend and implement remediation steps.
• Prepare files and materials for internal and external regulatory audits.
• Ensure data integrity throughout the reporting lifecycle.
• Collaborate with departments to prepare required materials and ensure clear communication of findings and recommendations.
• Provide guidance to junior staff and escalate higher-level issues to senior management as needed.
• Assist with various cross-departmental projects as assigned, contributing to the overall success of organizational initiatives.

Member Support Coordinator

Clinical Supervisor – Virtual Clinical Operations

Licensed Master Social Worker, LMSW

Enrollment Coordinator

Registered Dietitian

Senior Analyst, Data Infrastructure