Jobs

Description

Remote role

Summary:

• This position will conduct clinical member outreach calls as well as take inbound calls as it relates to all Quality Outreach Initiatives.
• This position will focus on members with HEDIS and Star care gaps that are high risk for non-compliance and will assist the member in eliminating barriers and close care gaps.

Responsibilities:

• Receives incoming calls from members emanating from quality outreach initiatives such as mailings, emails, phone calls, etc.
• Makes outgoing calls to educate members on the importance of closing gaps in care such as appropriate testing, periodical checkups, immunizations, counseling and provide health education materials.
• Maintain accurate member records from outreaches such as incoming calls, successful outreaches, member issues, and member roadblocks.
• Act as a liaison with providers, members and outside community resources by assisting with scheduling an appointment, warm transfers to member services, etc.
• Assure understanding level of each member by providing clear and complete information in accordance with company guidelines.
• Administer Rewards and Incentive programs for both Medicaid and Medicare members by sending out rewards, confirm member demographics, and educate members in regards to the R&I Program.
• Refer members to a Clinical Quality nurses as necessary.

Qualifications:

Education/Experience:

• Requires an Associates degree from an accredited college or university, preferably in healthcare field.
• In lieu of degree applicant must have 3 years of equivalent and relevant work experience.
• Requires 2 years work experience in case management, community health, Medicaid or health insurance environment.
• Requires a minimum of 2 years experience working with members to close gaps in care.
• Requires a minimum of 1 year managed care experience.

Additional licensing, certifications, registrations:

Knowledge:

• Requires knowledge of the Managed Care or Health Insurance Industry.
• Requires knowledge of medical terminology.
• Requires knowledge of PC's and windows based software applications.
• Prefer knowledge of Medicaid and Medicare regulations.

Skills and Abilities:

• Requires excellent verbal and written communication skills.
• Requires excellent service quality skills.
• Requires excellent organizational and interpersonal skills.
• Requires good decision making skills.
• Requires good problem solving/conflict resolution skills.
• Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint); Should be knowledgeable in the use of intranet and internet applications.