Care Coordination/Risk Scores
DS
Avg HCC Score
2.47
▲ 0.12 vs. prior year
Avg RAF Score
1.83
▲ 0.08 vs. prior year
High-Risk Members
312
▲ 18 from last quarter
Recapture Opportunities
$2.1M
147 members with gaps
Recapture Opportunity Alerts
89 members have suspected HCC conditions not yet coded in 2025
Estimated revenue impact: $847,000. Schedule AWV appointments to capture diagnoses before sweep date.
CMS RAF final submission sweep: 58 days remaining
Current capture rate: 71.3%. Target: 85%+ for full reimbursement. 147 chase letters queued for provider outreach.
RAF Score Trend — 12 Months
Avg RAF Target
2.10
1.90
1.70
1.50
Apr '24JunAugOctDecFeb '25Mar '25
Risk Tier Distribution1,847 total members
1,847
Members
Critical (RAF≥3.0) — 314
High (2.0–2.99) — 517
Medium (1.0–1.99) — 572
Low (<1.0) — 444
RAF Score Breakdown by Condition Category
Cardiovascular Disease
0.42
Diabetes Complications
0.35
COPD / Respiratory
0.28
Chronic Kidney Disease
0.24
Mental Health Disorders
0.21
Cancer / Neoplasms
0.17
Neurological Disorders
0.13
Musculoskeletal
0.10
Patient Risk Score Table
1,847 members
PatientHCC ScoreRAF ScoreRisk TierSuspected ConditionsLast CalculatedActions
Eleanor Mitchell
DOB: 03/12/1938 · ID: M-00142
8.2 3.41 Critical CHFCKD+2 gaps Today
Robert Johnson
DOB: 07/28/1935 · ID: M-00089
7.8 3.18 Critical COPDT2DM+4 gaps 5 days ago
Maria Gonzalez
DOB: 11/05/1940 · ID: M-00217
5.4 2.67 High HTNDiabetes Yesterday
William Chen
DOB: 05/19/1933 · ID: M-00334
4.9 2.41 High CHF+1 gap 2 days ago
Dorothy Patterson
DOB: 02/14/1937 · ID: M-00451
3.2 1.88 Medium Depression 1 week ago
Harold Lewis
DOB: 09/30/1942 · ID: M-00512
2.8 1.62 Medium ArthritisAsthma 3 days ago
Beatrice Thompson
DOB: 06/08/1936 · ID: M-00673
1.4 0.94 Low Hypertension Today
James Morrison
DOB: 12/22/1939 · ID: M-00789
4.1 2.29 High CKD+3 gaps 18 days ago
Showing 8 of 1,847 members
AI Assistant
How do I open a new care coordination case?
Go to Care Coordination > Cases and click "New Case". Assign a care manager, set priority, and link to the patient chart.
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How do I track transitions of care?
Navigate to Care Coordination > Transitions. All hospital admissions, discharges, and ER visits trigger transition alerts.
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How do I document a care coordination interaction?
From any case, click "Add Interaction". Log the contact method, duration, topics covered, and follow-up tasks.
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How do I manage clinical alerts?
Go to Care Coordination > Clinical Alerts. Unacknowledged alerts are highlighted in red. Assign or dismiss with a reason code.
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How do I update a care plan from coordination?
From the care coordination case, click "View Care Plan" to open and edit the linked patient care plan in context.
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How do I handle high-risk patients?
High-risk patients are flagged automatically by the risk engine. Assign intensive case management from the risk scores dashboard.
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How do I log CCM time?
In the patient chart, go to the CCM Log tab. Each interaction logs time automatically. Monthly totals roll up for billing.
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How do I manage the care team?
Go to Care Coordination > Team to view all care managers, their caseloads, and performance metrics.
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