Clinical Coordination & Quality Improvement: - Oversee proactive identification of high-risk members (e.g., chronic conditions, frequent ED utilizers, at risk for readmissions) and implement mitigation strategies- Ensure timely post-discharge follow-up which may include appointment scheduling, program enrollment, coordination with home health, rehabilitation or social services and provide member education related to self-management and warning signs- Assist with root-cause analysis of readmissions and adverse events related to TOC failures- Monitor and report key metrics including: 30-day readmission rates, time-to-first follow up, member satisfaction and provider satisfaction (30%). Stakeholder Engagement: - Build and maintain strategic relationships with hospital discharge planners, care managers, emergency department leadership and post-acute care facilities- Be a spokesperson for TOC best practices and socialize health plan TOC and other care management programs and resources- Collaborate with utilization management, pharmacy and health outcomes teams to address barriers to care (25%).