Student Veterans of America Jobs

Job Description

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

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 LPN/LVN or RN , 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

• Role requires working onsite at providers office.

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: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com 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.