Clinical Care Coordinator - RN
Humana - Rogers, AR

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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

Key Competencies

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.

Qualifications

Role Essentials

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

Role Desirables

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

Reporting Relationships

You will report to a Manager or Supervisor. This area is under the leadership of the SVP & Chief Operating Officer.

Additional Information

Schedule

:

Full-time

Primary Location

:

US-AR-Rogers

Role

:

Clinical Innovations and Health Practitioners

Work Environment Type

:

Office

Travel

:

Yes, 20 % of the Time

Humana - 17 months ago - save job - block
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Humana Inc. (Humana) is a full-service benefits solutions company, offering an array of health and supplemental benefit plans for employer...