This position is accountable for supporting physicians and the delivery system to improve member’s health outcomes and participate in the company’s STAR initiatives by: 1) Assisting the providers in delivering improved patient care and 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 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 is required to identify opportunities to improve satisfaction and quality.
Essential Job Functions
• Identify opportunities for improvement and provide staff education on the health plan’s STAR initiatives, to include HEDIS and CAHPS and HOS surveys as it relates to improving member experience and health outcomes.
• Participate in meetings with concurrent review nurses, transitions of care nurses, skilled nursing, acute inpatient rehabilitation, long term care nurses and embedded case managers (if applicable) to ensure that all inpatient members have been addressed/assigned to appropriate care programs.
• Utilize health analytic tools (e.g. BI tool) to identify trends and opportunities (within a population in a specific geographic area) to enhance the health of Florida Blue members and support value based arrangements and collaborative care providers with management of their members.
• Assist members to obtain preventive screenings and review for adherence with prescribed medications
• Obtain and supplemental data contained in the medical record and make it available to the health plan for integration into the HEDIS data base.
• Participate in the health plan’s initiatives to achieve CMS goals for QIPs and CCIPs.
• Partner with the Population Care Manager (PCM) to identify/address safety and readmission opportunities.
• Inform and educate the care team on care gaps, activities, issues or concerns about the population and from the value based programs.
• Collaborate with Member, Member’s Physicians, Plan Medical Directors, Managers, Local, Regional and Specialty team members as well as other functional area to assist the member to meet their health care goals, reduce care gaps, improve health outcomes, and reduce the total cost of care.
• Investigate Potential Quality of Care issue (PQI) within regulatory guidelines within a geographic region.
• Identify and report on healthcare disparities within a geographic region.
• Support Retail Center quality events.
• Be familiar with the BI Tool, Diamond system, MD source, Healthcare Analytics tool, JIVA, SharePoint/Archer, MedQ, and vendor systems.
• Assist in medical chart review and data collection during HEDIS season.
• Perform other duties as assigned.
Minimum Job Requirements
• Current Florida RN license (or receives a Florida RN license within 1 month or agreed upon timeframe of hire)
• Bachelors’ degree in related field (i.e. Nursing, Healthcare, Business) or equivalent experience
• 4+ years’ experience in health insurance or managed care (defined as previous experience with health plan/hospital compliance, risk management). Previous case management experiencepreferred.
• 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