This position is accountable for supporting Primary Care Practices to improve patient health outcomes for their current Medicare population. The requirements for this position include: 1) Assisting the providers in delivering improved patient care and a decrease in hospital readmissions and misuse of emergency visits. 2) Enhance traditional case management programs by physically and geographically integrating nurses into the local provider community. 3) Support the POD case management delivery system through assuring timely PCP follow-up and compliance with treatment plans for members with chronic conditions. 4) Educate the provider community on the impact of CAHPS, HOS, and HEDIS on member outcomes and STARs performance. 5) Assess provider office practices for opportunities for improvement to positively impact member experience and impact CAHPS and HOS ratings. This position will be required to communicate and collaborate with Value Based and non-valued based partners as well as other stakeholders to effectively manage the delivery of strategies, plans and improvements to HEDIS, Medicare Stars, Qualified Health Plans/Quality Rating Systems and other clinical quality measurements. Knowledge and utilization of health analytic tools are required to identify opportunities to improve satisfaction and quality.
4+ years related work experience or equivalent combination of transferable experience and education
Health insurance or managed care (defined as previous experience with health plan/hospital compliance, risk management). Previous case management experience preferred.
Experience or working knowledge of HEDIS, Stars and the Qualified Health Plan/Quality Rating System
Ability to interact with medical staff, peers, and internal company staff at all levels
Experience working within the following value structure: Respect; Integrity, Imagination, Courage and Excellence
Non-traditional working hours to meet the member's availability
Basic to intermediate experience in MS Word, Excel, tablet and/or smartphone
Travel up to 30% (subject to change) for on-site member/provider meetings, events or manager requests with occasional overnight stays
Must have valid driver's license and reliable transportation
Ability to talk and type simultaneously.
Bachelor’s degree or equivalent work experience
RN - Registered Nurse - State Licensure And/Or Compact State Licensure
Job Type: Contract