Maria Jose Saldana Saldana

Key​ ​Responsibilities: ● Completes holistic risk assessment via preferred personal interview format ● Coordinates services with care manager ● Coordinates with CM personnel in transmission of clinical treatment to patients, families and outside agencies (i.e. trans, Medicaid, patient assistance programs, etc.) ● In collaboration with care manager, executes evidence based practice in individualized patient care plans ● Identifies community resources and recommends alternative services and support outside of the health system which may benefit patient ● Facilitates referrals to connect patient with non-clinical and community services for non-clinical and social support ● Recommends alternative services and support outside of the health system ● Encourages patients to follow prescribed course of access (e.g., patient assistance programs, local support programs) offered through support referrals ● Arranges and monitors physician and agency support appointments ● Acts as liaison for acute facilities, post- acute facilities, outside agencies and outside providers as directed by care manager

Key Responsibilities: Conducts Telephonic Assessments Prepares individualized care plans for clinical review Assist Case Manager & Non-Clinical Care Manager to coordinate interventions Serve as primary contact for high-risk members Responsible for identifying member risk and communicating changes in member’s health status as appropriate Identifies and effectively utilizes health plan benefits and community resources to meet the needs of members and caregivers Makes appropriate referrals to other programs to address the member’s needs

Key Responsibilities: Completes telephonic risk assessment Works with Case Manager to develop individualized care plans Assist in coordination of services with care manager Provides ongoing outreach to member and caregivers