Responsible for managing annual and proactive HEDIS (PAH) for compliant/ non-compliant population, Health Choices/Commercial prenatal-postpartum (PNPP) population as assigned. Responsible for and evaluated against success with outreach to assigned HEDIS/PNPP member case load. Responsible for retrospective medical record review to obtain clinical quality data per the HEDIS/PNPP specifications set forth by the National Committee for Quality Assurance (NCQA). Collaborates with the Health Plan members and primary care providers in multiple practice sites to facilitate clinical guideline adherence and coordinates services as needed. Contributes to the design and implementation of interventions developed by quality improvement workgroups to achieve the goals and objectives defined within the Health Plan's Quality Plan and Work plan.
Demonstrates understanding of the regulatory agency standards by participating in annual educational sessions.
Manages assigned member caseload to execute appropriate interventions to drive population outcomes and assist Health Plan to attain high quality rates and rankings.
Responsible for conducting medical record reviews including physician progress notes, laboratory data, radiology and imaging reports, consult notes, etc.
at multiple primary care locations to collect criteria established by CMS, NCQA and other regulatory agency standards with little or no oversight by management.
Demonstrates timely and accurate documenting of collected medical record data in the Quality database per department standards.
Independently reviews targeted measures and collaborates with practitioners or members to ensure follow-up care is provided within the timeframe of established guidelines.
Accurately documents relevant data into database.
Tracks member compliance reports and executes appropriate interventions for non-compliant members, including direct contact with members, other primary care personnel and facilities as needed.
Educates and collaborates with primary care physicians and site personnel regarding specific quality standards, targeted strategies to drive quality outcomes, and the support available to them through the Health Plan.
Works with assigned provider office staff to educates members regarding the importance of preventive health guidelines.
Works collaboratively with Health Choices population as an educator and clinical resource to encourage proactive process to ensure optimal compliance with regulatory standards such as prenatal and postpartum services, risk assessment, care coordination, health and nutrition education and other preventive screenings.
Participates as a voting member within the member appeals process as appropriate and needed.
Identifies opportunities for modifications in processes and assists Management with implementation of the same.
Responsible for reporting quality or potential fraudulent issues identified through daily activities.
Responsible for referring members for Health and Case Management when appropriate.
Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.
Graduate from Specialty Training Program-Nursing (Required)
Minimum of 5 years-Nursing (Required)
Certification(s) and License(s)
Licensed Practical Nurse - Default Issuing Body
We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
At Geisinger, our innovative ideas are inspired by the communities we serve – like our Fresh Food
Farmacy, a program that delivers life-saving healthy alternatives to patients with diabetes. With additional tools like our MyCode Community Health Initiative, one of the first health system genome sequencing
programs, and our new asthma app suite that we developed in partnership with AstraZeneca, it’s no wonder we’re ranked one of the Top 5 Most Innovative Healthcare Systems by Becker's Hospital Review. We continually work towards continuous improvement in a culture where everyone has a voice and firmly believe that better begins with all of us.
Founded more than 100 years ago, Geisinger serves more than three million residents throughout central, south-central and northeastern Pennsylvania and southern New Jersey. Our physician-led system is comprised of 30,000 employees, including 1,600 employed physicians, and consists of 13 hospital campuses, the Geisinger Health Plan, Geisinger Commonwealth School of Medicine and two research centers.
What you do at Geisinger shapes the future of health and improves lives – for our patients, communities, and you.