Contacts members, educating them about the annual services that are needed as outlined by HEDIS. Assists with coordinating contact and following through with member's Primary Care Physician. Meets the neutral standards established by the State of Maryland but strives for the VBP incentive range. Fulfills the outreach contractual criteria required by the State of Maryland and assists MedStar Family Choice providers with outreach to members including those members who have been non-compliant or are difficult to reach.
High school graduation or equivalent. Associate's degree or related certification preferred.
6 months customer service experience in a managed care or social service setting; Medicaid experience preferred.
Medical Assistant certification or equivalent preferred.
Knowledge, Skills & Abilities
Typing and filing skills. Working knowledge of Microsoft Word, Excel, Access and PowerPoint applications. Effective verbal and written communication skills.
Primary Duties and Responsibilities
Accurately documents all member appointments and outreach efforts, successful and unsuccessful, in the computer system per MSFC policy/audit tool. Based on the assigned Chronic Care Program may be responsible for obtaining a copy of the completed services to track compliance and overall utilization score.
Assists the Quality Improvement Department with the collections of clinical records utilizing Centricity, Amalga, lab database, etc. during the annual HEDIS audits.
Attends required meetings and participates on committees as requested.
Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.
Demonstrates behavior consistent with MedStar Health mission, vision, goals, objectives and patient care philosophy.
Develops and implements member incentive programs to encourage compliance with annual chronic care services. Assists with special mailings and program drawings, and gift card mailings when indicated, for assigned Chronic Care Program.
Facilitates member understanding and utilization of the MSFC Benefit Plan, resolves member inquiries, and assists the patient in coordinating care or services when requested or required.
For assigned program, develops and implements strategies to engage members with the annual service requirements as established by the State of Maryland and NCQA (HEDIS). Coordinates appointments as necessary; educates members about the importance of ongoing preventative care and services; facilitates and supports the member’s relationship with their PCP or Specialist; and. works collaboratively with RN Disease Manager.
Generates case management referrals and quality referrals as needed.
Maintains the "macro reporting" database which refreshes monthly enabling proactive statistics on compliant members for assigned program and an active list of members to call and coordinate annual care appointments.
Performs other duties as assigned.
Processes transportation requests for members when criteria are met. Accurately documents transportation services per MSFC policy.
Processes Welcome-Orientation calls when contacted by a new MedStar Family Choice Member and documents in the computer system per CCMS.
Provides ACD telephone coverage and processes calls related to PCP and provider questions, eligibility and benefits, transportation, and authorization issues.
Utilizes a multitude of systems to locate members and coordinate care. Enters corrected contact information in CCMS and forwards reminders to Vestica (TPA). Completes Local Health Department and documents follow up results from this agency when demographics are inaccurate.
About MedStar Health
MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation and research. Our 30,000 associates and 5,400 affiliated physicians work in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest visiting nurse association in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar is dedicated not only to teaching the next generation of doctors, but also to the continuing education and professional development of our whole team. MedStar Health offers diverse opportunities for career advancement and personal fulfillment.