Three or more years of experience with data analysis/quality chart reviews. Three or more years of healthcare experience to include experience in a managed care setting Prior HEDIS/STAR experience or participation with similar regulatory reporting Maintains education/knowledge base of HEDIS/STARs standards and guidelines Provides reports and monitors performance at local level Supports and assists PCPs/clinics with quality data collection Decision making skills will be based upon the current needs of the member and require an understanding of disease processes and terminology and the application of clinical guidelines but do not require nursing judgmentĪnalyze data, evaluate for possible data integrity and data deficits and document findingsĪnalyze and trend HEDIS/STAR rates, identify barriers to improvement of rates and create interpretive exhibits
Participates in coordinating care for members with chronic illnesses, co-morbidities, and/or disabilities as directed by responsible RN, and in conjunction with the RN, member and the health care team, to ensure cost effective and efficient utilization of health benefits. Provides all information collected to the responsible RN, who verifies and interprets the information, conducts additional assessments, as necessary, and develops, monitors, evaluates, and revises the member's care plan to meet the member's needs Obtains clinical data as directed by the responsible RNĪssists the responsible RN in identifying members that would benefit from an alternative level of care or other waiver programs Revise Patient Treatment Plan as necessary, based on evaluation of patient’s condition and response to nursing careĮvaluate and document the response of patients and/or family to teachingĭemonstrate responsiveness to team members by listening, providing support, or referring to appropriate source for assistance, if necessaryĬommunicate with Clinical Director or Charge Nurse regarding new or temporary employees assigned to the unitĪssisting the responsible RN with telephonic and face-to-face assessments for the identification, evaluation, coordination and management of member's needs, including physical health, behavioral health, social services and long term services and supportsĪssists responsible RN in identifying members for high risk complications. Instruct the patient and/or family in identified knowledge and/or skills deficits Consider social, cultural, and economic factors as they relate to specific patients and families and document this information on the plan of careĭemonstrates knowledge of medications and IV solutions in terms of purpose, side effects, and contraindications in the adult, geriatric patient Include the patient and family in formulating the plan of care. Assess patient’s psychosocial status and needsĬontribute to maintenance of the Patient Treatment Plan after it has been initiated by R.N Applies individual reasoning to the solution of a problem devising or modifying processes and writing proceduresĪssess the patient and family needs and complete admission assessment documentation. Decision making is usually based on prior practice or policy, with some interpretation.Collaborates with the nurse manager to recommend policies, procedures and standards which affect the care of the patient with high-risk chronic disease diagnoses such as CHF, IHD, COPD/Asthma and Diabetes.Instruct the member on how to access the program resources, suggest and/ or arrange follow-up including mailing of educational materials, contact with community resources, facilitate physician visits.
Provide telephonic follow up with members for case management services once discharged from facility, or once member has been stratified at a level requiring case management follow up.Pulls tasking report from disease management database and conducts Chronic Care Model follow-up phone calls to eligible CCM enrolled members who have set self-management support goals within 2 weeks of date tasked.Conducts Chronic Care Model visits and reviews the patient’s informal and formal support systems, focusing on what patients want to improve and educating them about their chronic disease.Works with the PCP and clinic staff to identify patients with high risk diagnoses such as CHF, IHD, COPD/Asthma and Diabetes and ensures clinical guidelines are being followed.