LPN/LVN or RN Value Based Care Nurse- Mobile, AL and Surrounding Counties (Onsite at Providers Offic

Job Description

Primary Function:

Coordinate and manage relationships with participating provider practices.

Maintain detailed understanding of HEDIS / STAR/ CAHPS performance measures.

Develop and maintain a process to ensure all customers in participating provider practices meet all quality metrics.

Supports the delivery of cost-effective, quality -based health care services for health plan customers by development and implementation of alternative treatment plans that address individual needs of the customer, their benefit plan, and community resources.

Plans, implements, and evaluates appropriate health care services in conjunction with the physician treatment plan.

Utilizes clinical skills to assess, plan, implement, coordinates, monitor and evaluates options and services in order to facilitate appropriate healthcare outcomes for customers.

Responsibilities:


* Identifies Quality gaps and metrics for customers and communicates to provider


* Review STAR summary gap report (daily) by payor


* Reviews Arcadia polychronic reports


* Clinical review of charts for clinical documentation integrity ( # Charts Reviewed to TBD by polychronic report threshold)


* Query provider based on clinical chart findings


* Follow up and track provider query's (weekly)


* Maintains physical presence in participating provider practices


* Identifies high-risk/high-cost patients for possible case management intervention and refers to appropriate clinical program.


* Interfaces with providers of medical services and equipment to facilitate effective communication, referrals, supports discharge planning, and alternative treatment plan development.


* Identifies customer needs, coordinates and supports planned and unplanned transitions and post discharge follow up calls which may include primary care physician and specialist appointment scheduling


* Nurse notifies PCP daily of admissions and discharges


* Collaborates with the attending physician to achieve identified patient outcomes.


* Tracking of monthly IPM reports by PCP


* Attend and participate in weekly team or provider meetings


* Collaborates with supervisors, team members, and utilizes buddy system for back up coverage


* Performs telephonic outreach as directed


* Communicates with all departments to resolve issues


* Understands and follows administrative guidelines (policy and procedure) of the department


* Attends and actively participates in staff meetings.


* Requires on camera participation


* Attends clinical documentation integrity training


* Provides detailed clinical chart review to verify chronic conditions and related symptoms


* Support Chart reviews and Pulls medical records for HEDIS


* Supports Health Plan with CAHPS and STARS initiatives


* Extract data as needed and document in appropriate system


* Other Duties as assigned.

Supervisory Responsibilities:


* None

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