Medicare Programs Clinical Lead

Careers With Purpose Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America's heartland. Facility: GSS National Campus Location: Sioux Falls, SD Address: 4800 W 57th St, Sioux Falls, SD 57108, USA Shift: 8 Hours - Day Shifts Job Schedule: Full time Weekly Hours: 40.00 Salary Range: $31.00 - $49.50 Department Details Integral part of the Sanford Health Plan Great Plains Medicare Advantage Institutionalized Special Needs Program (ISNP). Relationship building with the programs providers that are at the frontlines providing care to the members to ensure seamless care. Working with several team within Sanford Health Plan as well as the Long Term Care Facilities to support a successful INSP program, following the Model of Care. Job Summary Leads clinical operations of Medicare programs with a primary focus in model of care development and delivery, healthcare effectiveness data and information set (HEDIS), Medicare star rating, Chronic Care Improvement (CCIP) and risk adjustment . Works closely with Sanford leadership and provider groups to ensure the model of care is carried out to members consistently and meets regulatory requirements. Assumes the role as subject matter expert on the model of care and super trainer on the delivery of that model of care to plan providers and provider groups. Develops, implements, and maintains a CCIP and Quality Improvement Projects (QIP). Participates in the quality improvement committee(s) established as a result of participation in Medicare programs. Completes gap assessment of healthcare effectiveness data and HEDIS measures and ensures providers are equipped to close remaining HEDIS gaps. Monitors star ratings and formulates action plans to achieve a four star or above rating. Interacts with Medicare clinical pharmacist to streamline the delivery and increase the effectiveness of the plan's model of care. Researches and helps strategize model of care delivery required for existing and new programs. Utilizes various resources to ensure providers are trained in the model of care. Consults with the care management team in an effort to create high-value clinical outcomes for members. Ensures the EMR and/or other care management platform workflows, templates and documentation are created to fulfill all relevant HEDIS categories. Drives quality improvement initiatives to ensure HEDIS and CCIP gaps are addressed and star ratings are optimized. Monitors model of care metrics and takes action to achieve performance goals. Coaches providers and completes chart reviews to ensure completeness of documentation and appropriate model of care delivery based on members care needs, risk stratification and other relevant variables. Collaborates with IT to ensure that the collected HEDIS data is included in data files submitted to the payer and troubleshoots as necessary. Assists with the quality improvement review and audit related to potential quality risk issues and adverse events as part of any Medicare quality risk program. Completes chart reviews, documentation of findings, referral for medical director review and required reporting. Analyzes member risk score data and determines members that may not have all active diagnoses captured. Stratifies members and identifies any hierarchical condition categories (HCC) that may be over/under reported and determine appropriate actions, which may include working with other departments and/or providers. Oversees the annual chart review process which includes validating the scope of medical record request list, completing oversight on any delegated vendors and ensuring providers are responding to requests. Must be analytical and have critical thinking, problem solving and decision making skills. Must be organized and able to multi-task. Must be proficient in computer software such as Epic, Care Coach, Point Click Care, Word and Excel. Qualifications Bachelor's degree in nursing required. Graduate from a nationally accredited nursing program preferred, including, but not limited to, Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), and National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA). Minimum of five years of nursing experience. Experience and knowledge of accreditation and regulatory agency standards preferred. Quality, medical coding, and/or risk adjustment experience is preferred. Currently holds an unencumbered RN license with the State Board of Nursing where the practice of nursing is occurring and/or possess multistate licensure if in a Nurse Licensure Compact (NLC) state. Obtains and subsequently maintains required department specific competencies and certifications. Benefits Sanford offers an attractive benefits package for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 401(k) retirement plan, work/life balance benefits, and a generous time off package to maintain a healthy home-work balance. For more information about Total Rewards, visit . Sanford is an EEO/AA Employer M/F/Disability/Vet. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-877-673-0854 or send an email to talent@ . Sanford has a Drug Free Workplace Policy. An accepted offer will require a drug screen and pre-employment background screening as a condition of employment. Req Number: R-0253288 Job Function: Health Plan Featured: No

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