Primary Function : Coordinate and manage relationships with participating provider practices.
Maintain detailed understanding of HEDIS / STAR performance measures. Develop and maintain a process to ensure all customers in participating provider practices meet all quality metrics.
Responsible for coordinating the delivery of cost-effective, quality based health care services for health plan customers by development and implementation of alternative treatment plans that address individual needs of the customer, their benefit plan, and community resources.
Plans, implements, and evaluates appropriate health care services in conjunction with the physician treatment plan.
Utilizes clinical skills to assess, plan, implement, coordinates, monitor and evaluates options and services in order to facilitate appropriate healthcare outcomes for customers.
Responsibilities :
- Identifies gaps in needed quality metrics for customers and communicates to provider
- Maintains physical presence in participating provider practices
- Identifies high-risk / high-cost patients for possible case management intervention.
- Interfaces with providers of medical services and equipment to facilitate effective communication, referrals, development of discharge planning, and alternative treatment plan development.
- Identifies customer needs, coordinates and supports planned and unplanned transitions and post discharge follow up calls which may include primary care physician and specialist appointment scheduling
- Collaborates with the attending physician to achieve identified patient outcomes.
- Attend and participate in weekly Complete Health Team rounds
- Perform telephonic outreach or home visits, as needed
- Communicates with all departments to resolve issues or document trends.
- Understands and follows administrative guidelines (policy and procedure) of the unit.
- Attends and actively participates in staff meetings.
- Other Duties as assigned. Supervisory Responsibilities :
- None
Ideal candidate must be available to work onsite at providers office.
Experience :
- Current Licensure as a Registered Nurse, in the state of Alabama in good standing.
- Associates degree, diploma or B.S. in Nursing
- Three to Five (3-5) years recent experience in an acute-care environment, case-management or utilization management position (experience can be a combination of LVN / RN licensure)
- Previous HEDIS and / or CMS STARs experience a plus
Job Related Skills :
Verbal and written communication skills
- Interpersonal skills
- Basic Mathematical and statistical ability
- Organizational skills
- Typing and computer knowledge- able to type 35WPM
- Knowledge of utilization review requirements and procedures
- Knowledge of current health care practices and appropriate treatments.
- Knowledge of community resources
- Ability to travel to and work at participating provider offices
- Works independently with minimum of supervision
- Bilingual preferred Spanish both conversational and written
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