Nurse will perform outreach calls to Medicare members that have been identified as having 'care gaps' on their Health Risk Assessment form in order to close the gaps for the member's health benefit and support the health plan in achieving and maintaining a higher Medicare 'Star Rating' as defined by The Centers for Medicare and Medicaid Services (CMS).
Roles and Responsibilities
• Conducts outreach calls to Medicare members of health plan to gather the appropriate/necessary clinical data to 'close' identified care gaps.
• Applies clinical/'soft' case management skills to close care gap and complete appropriate documentation.
• Maintains quality and productivity standards as outlined in the Service Level Agreement.
• Ensures the integrity and high quality of calls made to Medicare members of health plan.
• Adheres to accreditation, contractual and regulatory guidelines.
• Maintain the highest level of confidentiality and professionalism at all times.
• Strictly follows company policies related to the handling, release and disposal of confidential information.
• Ensures that the Operations Manager or designee is made aware of any potential risk management issues in a timely manner.
• Consistently meets medical management standards for attendance and punctuality.
• At all times treats others with dignity and respect.
Job Licensure and Qualifications
- Current, active and unrestricted RN license preferred
• RN License
• *Knowledge of Centers for Medicare & Medicaid Services (CMS).
• *Experience in HEDIS and Medicare guidelines.
• Intermediate Microsoft Word, Excel, Outlook skills.
• Proficient in navigating through multiple computer applications.
• Excellent communication, time management, critical thinking, and problem solving skills.
• High School Diploma or equivalent
• AS or BS preferred