Medical VA, Nurse, Spanish Bilingual

1 . Conduct Comprehensive Health Risk Assessments (HRAs) Perform telephonic interviews with C-SNP members. Enter findings into the electronic health record or care management platform. Ensure documentation is complete, objective, and compliant with CMS guidelines. Code chronic conditions appropriately (e.g., HCC coding). 3. Engage and Educate Members Build rapport with members to encourage honest, open conversation. Educate members on preventive services, self-care, and available plan benefits. Address barriers to care (e.g., medication access, fall risks, language issues). 4. Identify and Flag High-Risk Members Recognize members with urgent needs or unmanaged conditions. Escalate cases to case managers, nurses, or care coordinators. Recommend follow-up visits or referrals (e.g., to PCP, specialist, or behavioral health). 5. Maintain Compliance and Timeliness Complete assessments within CMS and plan specific timeframes (e.g., within 90 days of enrollment). Follow all HIPAA and CMS privacy/security standards. Assist in meeting plan STAR ratings and quality improvement goals. 6. Collaborate with Care Teams Communicate findings to nurse case managers or interdisciplinary teams. Contribute to Individualized Care Plans (ICPs) for each C-SNP member. Help prioritize member outreach based on risk levels.