Title: Clinical Care Coordinator - RN
Role:Care Coordinator (PODS)
Assignment:Senior Products/Quality Initiative
Location: Rogers, AR
Are you a fit?
Do you enjoy working with medical members? Do you have a desire to be in a position where you can provide guidance to our member population as it is related to their health care needs? If so then read on!
You will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines review criteria.
* Examine clinical programs information to identify members for specific Case Management/Chronic Care / or Disease Management activities or interventions by utilizing established screening criteria
* Provider education on referral management and processes
* Monitor practice''s patient participation in Humana''s clinical programs.
* Promote Humana''s clinical programs and resources
* Facilitate member clinical program engagement
* Identifies areas to engage member clinical program participation.
* Consult with Clinical Program Case Mangers and nurses to identify member specific opportunities to address with a Provider
* Identify Chronic Complex members not participating in Humana Cares and refer PODS members to program
* Expertise on Clinical Programs available to PODS members, and ability to analyze available data to identify members who can benefit from available programs.
* Consult with PODS owner on Clinical Program opportunities needing addressed in a Provider visit
* Review member specific and provider specific data to identify concerns needing follow up by assigned Case Managers
* Identify medication usage opportunities needing Pharmacy Consultant involvement.
* Coordination of Clinical Program specific representation or input in to PODS Owner or Strategy Meetings
* Leveraging Technology: You are technological savvy and know how to appropriately share and use your knowledge to improve business results.
* Problem Solving: You are a problem solver with the ability to encourage others in collaborative problem solving. Acting as both a broker and consultant regarding resources, you engage others in problem solving without taking over.
* Is Accountable: You meet clearly stated expectations and take responsibility for achieving results.
* Clinical Knowledge: You understand clinical program design, implementation, management/monitoring to support choice in consumer medical care. Understands the medical utilization implications of such programs
* Communication: You actively listen to others to understand their perspective and ensure continuous understanding regardless of communication channel or audience.
* Active RN license in the state(s) in which the nurse is required to practice
* Ability to be licensed in multiple states without restrictions
* Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
* Ability to work with a team
* Valid driver's license and/or dependable transportation necessary (variable by region))
* Strong analytical skills, able to manipulate and interpret data
* Coding knowledge and experience
* Office practice/ hospital experience
* Organizational and prioritization skills
* Education: Bachelors or Associates degree in Nursing
* Health Plan experience
* Previous Medicare/Medicaid Experience a plus
* CMS Stars/performance measures/HEDIS knowledge and experience
* Call center or triage experience
* Utilization management knowledge and experience
* Provider and member rewards program knowledge and experience
* Experience in a state and/or federally regulated health care environment
* Understanding of clinical programs
You will report to a Manager or Supervisor. This area is under the leadership of the SVP & Chief Operating Officer.
Additional InformationRole: Clinical Innovations and Health Practitioners