Description

May be increased to 12 months, but not guaranteed.

• Provider outreach and Provider engagement to improve CAHPS and HEDIS/Stars measures.
• Lead improvement plans to impact overall CAHPS scores.
• May be required to assist Pharmacy with Medication Adherence calls.

Job Description:              

• Requires Nurse. This position will conduct clinical member outreach calls as it relates to all Quality Outreach Initiatives.
• This positon will focus on members with recent Emergency Department and Observation visits as well as members with HEDIS and Star care gaps that are high risk for non-compliance and will assist the member in eliminating barriers and closing care gaps.

Responsibilities:

• Makes outgoing calls to members with recent ER or Observations visits to assist with coordination of care, closing care gaps and providing chronic disease education. Receives incoming calls from members emanating from left messages.
• Assesses patient's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to members needs and aligned with benefit structure.
• Documents accurately and comprehensively based on the standards of practice and current organization policies. Including being comfortable using Excel or wants to learn Excel.
• Act as a liaison with providers, members and outside community resources by assisting with scheduling an appointment, warm transfers to member services, pharmacy ect..
• Assure understanding level of each member by providing clear and complete information in accordance with company guidelines.
• Refer members to Case management programs as necessary.

Education/Experience: 

• Requires an associate's or bachelor's degree (or higher) in nursing and/or a health-related field OR accredited diploma nursing school.
• Requires a minimum of two (2) years clinical experience
• Prefers 2 years work experience in case management, community health, Medicaid, Medicare or health insurance environment.

Additional licensing, certifications, registrations:

• Active Unrestricted NJ LPN or RN License Required.

Knowledge: 

• Requires knowledge of chronic disease management.
• Requires knowledge of PC's and windows based software applications.
• Prefers knowledge of the Managed Care or Health Insurance Industry
• Prefers knowledge of the standards of practice for care managers, coordination of services, and delivery of services.

Skills and Abilities:

• Independent worker, knows when to escalate to management.
• Requires excellent verbal, written and active listening communication skills.
• Requires excellent service quality skills.
• Requires excellent organizational and interpersonal skills.
• Requires sound decision making skills.
• Requires good problem solving/conflict resolution skills.
• Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint); Should be knowledgeable in the use of intranet and internet applications.