Description:

Position Purpose: 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.

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 providers office.

Conducts face-to-face education with the member and their family in the providers 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.

Skills:

HEDIS, managed care, quality improvement, RN, LPN, Social worker

Top Skills Details:

HEDIS

Additional Skills & Qualifications:

One of the following is preferred:

-Licensed Practical Nurse LPN

-Licensed Master Social Work LMSW

-Certified Social Worker C-SW

-Licensed Social Worker LSW

-Registered Nurse RN preferred

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

-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

Experience Level:

Intermediate Level

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

Diversity, Equity & Inclusion

At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through:

• Hiring diverse talent
• Maintaining an inclusive environment through persistent self-reflection
• Building a culture of care, engagement, and recognition with clear outcomes
• Ensuring growth opportunities for our people

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email actalentaccommodation@actalentservices.com for other accommodation options.