Works with members and providers to close care gaps, ensure barriers to care are removed, and improve the overall member and provider experience through outreach and face-to-face interaction with members and providers at large IPA and/or group practices.
Serves to collaborate with providers in the field, to improve HEDIS measures and provides education for HEDIS measures and coding.
Supports the implementation of quality improvement interventions and audits in relation to plan providers.
Assists in resolving deficiencies impacting plan compliance to meeting State and Federal standards for HEDIS.
Conducts telephonic outreach, while embedded in the providers' offices, to members who are identified as needing preventive services in support of quality initiatives and regulatory/contractual requirements. Provides education to members regarding the care gaps they have when in the provider’s office for medical appointments.
Schedules doctor appointments on behalf of the practitioner and assists member with wraparound services such as arranging transportation, connecting them with community-based resources and other affinity programs as available.
Maintains confidentiality of business and protects health information.
Must Have
HEDIS Experience.
Bachelor's Degree in Healthcare, Public Health, Nursing, psychology, Social Work, Health Administration, or related health field or equivalent work experience required.
Responsibilities
Acts as a liaison and member advocate between the member/family, physician, and facilities/agencies.
Acts as the face of WellCare in the provider community with the provider and office staff where their services are embedded.
Advises and educates Provider practices in appropriate HEDIS measures, and HEDIS ICD-10 /CPT coding in accordance with NCQA requirements.
Assesses provider performance data to identify and strategize opportunities for provider improvement.
Collaborates with Provider Relations to improve provider performance in areas of Quality, Risk Adjustment, Operations (claims and encounters).
Schedules doctor appointments for members with care gaps to access needed preventive care services and close gaps in care in the provider’s office.
Conducts face-to-face education with the members and their family, in the provider’s office, about care gaps identified, and barriers to care.
Conducts telephonic outreach and health coaching to members to support quality improvement, regulatory and contractual requirements.
Arranges transportation and follow-up appointments for members as needed.
Documents all actions taken regarding contact related to member.
Interacts with other departments including customer service to resolve member issues.
Refers to case or disease management as appropriate.
Completes special assignments and projects instrumental to the function of the department."
Education/Experience
Required A Bachelor's Degree in Healthcare, Public Health, Nursing, psychology, Social Work, Health Administration, or related health field or equivalent work experience required. (a total of 4 years of experience required for the position).
Work experience should be in direct patient care, social work, quality improvement or health coaching, preferably in a managed care environment. 2+ years of experience work experience should be in direct patient care, social work, quality improvement or health coaching preferably in a managed care environment.
License/Certification
One of the following is preferred. Licensed Practical Nurse (LPN); Licensed Master Social Work (LMSW); Certified Social Worker (C-SW); Licensed Social Worker (LSW); Licensed Registered Nurse (RN) preferred.
Seniority level
Entry level
Employment type
Full-time
Job function
Health Care Provider
Industries
Staffing and Recruiting
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