Job Description
Job Description:
Job Tittle: Patient Care Advocate (HEDIS)
Location: Remote - Georgia
Duration: 7 Months (Possible Extensions)
Shift: 8AM-5PM Mon-Thu on Fri 8AM-12PM EST, No OT No OT.
Position Purpose:
Works with members and providers to close care gaps, ensure barriers to care are removed, and improve the overall member and provider experience through outreach and face-to-face interaction with members and providers at large IPA and/or group practices. Serves to collaborate with providers in the field to improve HEDIS measures and provides education for HEDIS measures and coding. Supports the implementation of quality improvement interventions and audits in relation to plan providers. Assist in resolving deficiencies impacting plan compliance to meeting State and Federal standards for HEDIS.
- Conducts telephonic outreach, while embedded in the providers' offices, to members who are identified as needing preventive services in support of quality initiatives and regulatory/contractual requirements.
- Provides education to members regarding the care gaps they have when in the provider's office for medical appointments.
- Schedules doctor appointments on behalf of the practitioner and assists members with wraparound services such as arranging transportation, connecting them with community-based resources, and other affinity programs as available.
- Maintains confidentiality of business and protected health information.
Primary Responsibilities:
- Acts as a liaison and member advocate between the member/family, physician, and facilities/agencies.
- Acts as the face of WellCare in the provider community with the provider and office staff where their services are embedded.
- Advises and educators provide practices on appropriate HEDIS measures and HEDIS ICD-10/CPT coding in accordance with NCQA requirements.
- Assesses provider performance data to identify and strategize opportunities for provider improvement.
- Collaborate with Provider Relations to improve provider performance in areas of Quality, Risk Adjustment, and Operations (claims and encounters).
- Schedules doctor appointments for members with care gaps to access needed preventive care services and close gaps in care in the provider's office.
- Conducts face-to-face education with the member and their family in the provider's office about care gaps identified and barriers to care.
- Conducts telephonic outreach and health coaching to members to support quality improvement, regulatory, and contractual requirements.
- Arrange transportation and follow-up appointments for members as needed.
- Documents are all actions taken regarding contact related to members.
- Interacts with other departments, including customer service, to resolve member issues.
- Refers to case or disease management as appropriate.
- Completes special assignments and projects instrumental to the function of the department.
Education & Experience
Required:
- Bachelor's degree in healthcare, Public Health, Nursing, Psychology, Social Work, Health Administration, or related health field OR equivalent work experience (a total of 4 years of experience required for the position).
- Work experience should be in direct patient care, social work, quality improvement, or health coaching, preferably in a managed care environment.
- 2+ years of experience in direct patient care, social work, quality improvement, or health coaching, preferably in a managed care environment.
License/Certification (Preferred)
One of the following is preferred:
- Licensed Practical Nurse (LPN)
- Licensed Master Social Work (LMSW)
- Certified Social Worker (C-SW)
- Licensed Social Worker (LSW)
- Licensed Registered Nurse (RN)
Story Behind the Need Business Group & Key Projects
- Health plan or business unit: Corporate
- Team culture: Collaborative, patient-focused, quality-driven
- Surrounding team & key projects: Outreach to members transitioning to different PCPs, assisting with community events, scheduling member appointments, and engagement events.
- Purpose of this team: Improve HEDIS measures, close care gaps, and support member outreach efforts.
- Reason for the request: Additional need due to member transitions.
- Future hiring needs: Potential openings for Senior Patient Care Advocates.
Typical Day in the Role
- Daily Schedule:
- 80% of the time spent reaching out to members
- Conducting outreach calls (approx. 10 per day)
- Weekly touchpoints with the team
- Work environment: Remote
Candidate Requirements
- Education/Certification: Required: Bachelor's Degree; Preferred: LPN, Certified Dietitian, or Health Coach
- Years of Experience: 3-5 years of Clinical/HEDIS experience
Must-Have Qualifications:
- Clinical experience/HEDIS
- Strong outreach experience
- Healthcare background with a member-first mentality
Disqualifiers:
- Lack of healthcare mentality or poor member interactions
Performance Indicators:
- 60 calls per day
- 20% of calls must result in scheduled appointments
Job Tags
Work experience placement, Remote job, Shift work,