Hospital Reviewer
APS Healthcare - Hato Rey, PR

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Position Summary

Provides either site visits or telephonic services or both for covered members. Focuses on member engagement, education and empowerment to self manage their chronic health conditions. Supports and encourage healthy lifestyle choices, health promotion, and behavioral change through motivational interviewing and incorporating behavioral change theories to reduce long term effects of chronic disease.

Essential Functions

1. Provides one on one telephonic or in person health-coaching and consultation services to participants, within state licensure scope of practice requirements. Conducts health risk assessments, introduces case management services, identifies and addresses barriers to treatment adherence and educates members about healthy lifestyle choices within state licensure scope of practice requirements.
2. Collaborates with participants to establish goals and provides ongoing support to members they strive to make and sustain healthy lifestyle choices. Provides participants with educational material and program introductory material, providing reinforcement of educational topics.
3. Collaborates with primary care/treating physicians as well as medical home and other healthcare professionals to obtain specific & current health information in regards to members’ plan of care.
4. Reviews data from variety of sources to assist in identifying co-morbid conditions, hospitalizations, prescriptions and other factors that could impact the educational and support of the individual. Integrates data identify problems, set goals, plan interventions and determine overall health status within scope of practice.
5. Documents all activities per APS policies and procedures.
Completes other duties, special assignments and projects as assigned


Formal clinical degree in one of the following categories:
o Bachelor or Masters prepared in Social Work with licensing
o Bachelor Degree in Nursing with current licensure
o Masters prepared in Behavioral Health or related field such as counseling, psychology, marriage and family services, human development, etc. Certification or licensure in areas such as family therapy, professional counselor or related certifications in the behavioral health field (LCPC, LGPC, LPC). Must have state specific qualifications such as required (Qualified Mental Health Professional for example)

• Two - three years clinical experience preferred.
• Previous experience in a care management, quality improvement, medical record reviews, disease management, and/or case management preferred.
• Knowledge of Medicare/Medicaid
• Knowledge of adult learning and behavior change principles preferred
• Knowledge of chronic illnesses, co-morbidities and disease management
• Knowledge of community based resources
• Clinical assessment skills, within state licensure scope of practice requirements
• Crisis intervention skills, within state licensure scope of practice requirements
• Excellent written & verbal communication skills
• Telephonic interviewing skills
• Proficient in Microsoft Office, Internet/Web Navigation
• Prioritization and organizational skills
• Ability to assess patient health status, within state licensure scope of practice requirements.
• Ability to integrate data and evaluate to design meaningful interventions within state licensure scope of practice requirements.
• Must be able to prioritize and target interventions designed to support long term behavioral change within state licensure scope of practice requirements.

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