Rn Value Base Care Nurse - Onsite - Alabama, Mississippi

Primary Function:
Coordinate and manage relationships with participating provider practices. Maintain detailed understanding of HEDIS / STAR/ CAHPS performance measures. Develop and maintain a process to ensure all customers in participating provider practices meet all quality metrics. Supports the delivery of cost-effective, quality –based health care services for health plan customers by development and implementation of alternative treatment plans that address individual needs of the customer, their benefit plan, and community resources. Plans, implements, and evaluates appropriate health care services in conjunction with the physician treatment plan. Utilizes clinical skills to assess, plan, implement, coordinates, monitor and evaluates options and services in order to facilitate appropriate healthcare outcomes for customers.
Responsibilities:
Identifies Quality gaps and metrics for customers and communicates to provider
Review STAR summary gap report (daily) by payor
Reviews Arcadia polychronic reports
Clinical review of charts for clinical documentation integrity ( # Charts Reviewed to TBD by polychronic report threshold)
Query provider based on clinical chart findings
Follow up and track provider query’s (weekly)
Maintains physical presence in participating provider practices
Identifies high-risk/high-cost patients for possible case management intervention and refers to appropriate clinical program.
Interfaces with providers of medical services and equipment to facilitate effective communication, referrals, supports discharge planning, and alternative treatment plan development.
Identifies customer needs, coordinates and supports planned and unplanned transitions and post discharge follow up calls which may include primary care physician and specialist appointment scheduling
Nurse notifies PCP daily of admissions and discharges
Collaborates with the attending physician to achieve identified patient outcomes.
Tracking of monthly IPM reports by PCP
Attend and participate in weekly team or provider meetings
Collaborates with supervisors, team members, and utilizes buddy system for back up coverage
Performs telephonic outreach as directed
Communicates with all departments to resolve issues
Understands and follows administrative guidelines (policy and procedure) of the department
Attends and actively participates in staff meetings.
Requires on camera participation
Attends clinical documentation integrity training
Provides detailed clinical chart review to verify chronic conditions and related symptoms
Support Chart reviews and Pulls medical records for HEDIS
Supports Health Plan with CAHPS and STARS initiatives
Extract data as needed and document in appropriate system
Other Duties as assigned.
Supervisory Responsibilities :
None
Ideal candidate must reside or willing to drive to following areas: (based on assigned coverage area)
Birmingham, Cullman, FT. Payne, Huntsville, Mobile, Montgomery and Tuscalossa, AL.
Hattieburg, Petal, Columbia, Gulfport, Biloxi, MS.
Job Related Skills :
Utilizes critical thinking skills
Verbal and written communication skills
Interpersonal skills
Basic Mathematical and statistical ability
Organizational skills
Typing and computer knowledge- able to type 35WPM
Knowledge of utilization review requirements and procedures
Knowledge of current health care practices and appropriate treatments.
Knowledge of community resources
Ability to travel to and work at participating provider offices
Works independently with minimum of supervision
Bilingual – preferred Spanish both conversational and written
Experience :
Current Licensure as a registered nurse, in the state of residence in good standing.
Associates degree, diploma or B.S. in Nursing
Three to Five (3-5) years recent experience in an acute-care environment, case-management or utilization management position (experience can be a combination of LVN/RN licensure)
Previous HEDIS and/or CMS STARs experience a plus
If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.
About Cigna Healthcare
Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives.
Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.
If you require reasonable accommodation in completing the online application process, please email: [email protected] for support. Do not email [email protected] for an update on your application or to provide your resume as you will not receive a response.
The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.