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
Strong analytical skills
Ability to be licensed in multiple states without restrictions
Prior clinical experience preferably office practice or hospital setting
Ability to work independently under general instructions and with a team
Organizational and prioritization skills
Ability to collaborate with multiple departments
Valid drivers license and/or dependable transportation necessary (variable by region)
Education: BSN or Bachelors degree in a related field
CMS Stars/performance measures/HEDIS knowledge and experience
Understanding of clinical programs
Provider and member rewards program knowledge
Previous experience in case or disease management and utilization management
Experience in a state and/or federally regulated health care environment
Excellent PC skills specifically Excel and powerpoint
Bilingual is a plus
You will report to a Manager or Supervisor. This area is under the leadership of the SVP & Chief Operating Officer.
Work Environment Type
Yes, 10 % of the Time
Humana Inc. (Humana) is a full-service benefits solutions company, offering an array of health and supplemental benefit plans for employer...