Summary: Coordinates and manages member care with single office practices and/or multiple provider practices in the HealthSpring-Cigna P4Q program.
Responsible for providing support to members, their families, and physicians in addressing medical and social concerns. Educates patients and families to make informed personal health care decisions. Facilitates communication between patient, physician, health plan, and community.
Coordinate and manage member care in participating provider practices:
Under general supervision, responsible for identifying medium/ high risk members by utilizing predictive modeling reports for the assigned physician and/or practice. Identify gaps in care and document compliance.
Assists in coordinating the delivery of cost-effective, quality-based health care services for health plan members by incorporating physician/staff and other health plan services to address individual needs of the member, and awareness of community resources. Initiate contact with member/family, physician, and health care providers/suppliers to discuss the alternative treatment plan. Greet members at on-site visits and assess members that need an ECC visit to assure coordination.
Daily monitors, and evaluates inpatient admissions and discharge census and follows through for post discharge appointments and needs. Evaluates cases for quality of care.
Partner with in-office Point-of-Contact(s) to ensure member compliance and practice success: Coordinate real-time performance measure management.
Ensure that participating practices are driving improvement on P4Q Program performance measures. Review data for those members that are frequent users of healthcare resources to ensure they are receiving the proper care. Providing physicians case management support or assisting them with referrals to behavioral health.
Communicate real-time updates to identified team members. Develop and maintain a process to ensure that all members in participating practices receive the screenings and services needed within the given timeframe. Maintain detailed understanding of all P4Q Program (HEDIS STAR) performance measures.
Unrestricted Registered Nurse (RN) in the applicable state.
At least 3-5 years of related experience in a healthcare environment. Excellent written and oral communication skills; excellent problem solving skills; highly organized and proactive; ability to handle multiple tasks and set priorities; detailed oriented; works independently with minimum of supervision. Ability to travel to and work at participating practices.
Current licensure as a Registered Nurse (RN), or Certified Case Manager in applicable state. Minimum five years clinical practice experience in a providers' office, hospital setting.