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Position Summary:
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.
Background & Context:
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.
Key Responsibilities:
• Acts as a liaison and member advocate between the member/family, physician and facilities/agencies.
• Acts as the face of our organization 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 strategizes 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 member 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 member 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.
• Performs other duties as assigned.
• Complies with all policies and standards.
• Will work at provider offices in Kent County and New Castle County 5 days a week.
| Education/Certification | Required: 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) | Preferred: | ||
| Licensure | Required: NA | Preferred: RN, LPN, LMSW, LSW, Certified Social Worker | ||
| Years of experience required: 2 years. Work experience should be in direct patient care, social work, quality improvement or health coaching preferably in a managed care environment. Disqualifiers: Additional qualities to look for: | ||||
| 1 | Excellent customer service skills | ||
| 2 | Member and/or patient outreach and care gap closure (telephonic and/or in-person) | |||
| 3 | Familiarity with Medicaid, Medicare Advantage, or dual populations | |||