Bilingual

• Provide remote health coaching to members at risk for dialysis in both English and Spanish languages.
• Establish and maintain contact with assigned and active members via phone, text, and email.
• Obtain and utilize clinical information to develop an individualized member care plan and clinician-centered care plan per NCQA guidelines.
• Assess members' health status and care coordination needs.
• Collaborate with members’ health care providers as needed.
• Utilize motivational interviewing techniques, individualized care plans, and the Triple Aim framework to empower active Members to reach their health goals.
• Explain to new or inactive members the benefits of the Program as it relates to chronic kidney disease and those at risk; encourage enrollment.
• Appropriately document, request, and send member information in accordance with HIPAA compliance.
• Meet individually assigned metrics, including call volume and enrollment requirements; proactively assess and revise approach using multiple forms of communication.

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