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 providers 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 protected health information.
REPORTS TO: DIRECTOR, QUALITY IMPROVEMENT
DEPARTMENT: KY HEALTH SERVICES-QI STATE
POSITION LOCATION: LOUISVILLE, KY 40223
- 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 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 for members as needed.
- Arranges 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.
- Position may be located in a provider's office
- Bachelor's Degree in Healthcare, Public Health, Nursing, psychology, Social Work, Health Administration, or related health field or equivalent work experience (a total of 4 years of experience) is required
- 2 years of work experience in direct patient care, social work, quality improvement or health coaching preferably in a managed care environment is required
- Demonstrated interpersonal/verbal communication skills
- Demonstrated written communication skills
- Ability to create, review and interpret treatment plans
- Ability to effectively present information and respond to questions from families, members, and providers
- Ability to multi-task
- Ability to work in a fast paced environment with changing priorities
- Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Ability to analyze and interpret financial data in order to coordinate the preparation of financial records
- Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Demonstrated organizational skills
- Ability to work independently
- Knowledge of healthcare delivery
- Appreciation and sensitivity towards cultural diversity and targeted populations
Licenses and Certifications:
A license in one of the following is required:
- Licensed Practical Nurse (LPN) is preferred
- Licensed Master Social Work (LMSW) is preferred
- Certified Social Worker (C-SW) is preferred
- Licensed Social Worker (LSW) is preferred
- Licensed Registered Nurse (RN) is preferred
- Proficient in Microsoft Office such as MS Word, MS Excel and MS Outlook is required
- Ability to use and navigate health service management systems is required
- Intermediate Healthcare Management Systems (Generic) is required
- Bilingual (English/Spanish) is preferred