RN I, Commercial Risk Adjust

This position will perform care management duties specifically targeting high-risk members within Medicare Advantage/Commercial risk adjusted populations to enhance the deployment of risk adjustment tactics. This position will work closely with the Care Management and Risk Adjustment Management (RAM) teams, including the RAM Manager & RAM Business Analysts to assess the health status of high-risk members on an annual basis and will work to engage these members in preventative care opportunities & screenings, including opportunities in provider office or retail settings if possible. This position is responsible for performing RN duties for members in Medicare Advantage/Commercial risk adjusted products, using established guidelines to ensure appropriate level of care, as well as, planning for the transition to the continuum of care and developing a member centric plan of care. When appropriate, there will be responsibility for ensuring members are engaged for annual wellness visits. This position will leverage analytical insights from RAM to create clinical strategies that drive encounters for high-risk members that support Medicare Advantage/Commercial risk adjustment initiatives. Positions involving the Medicare Advantage/Commercial risk adjusted population require travel.

Responsibilities:

• Facilitates the navigation of high-risk members to appropriate settings of care for annual wellness visits, including outreach to members, providers and retail pharmacies.

• Coordinates transition of member from RAM RN to care management RN based qualification for CM program and member commitment to participation.

• Encourages member participation and compliance with care management programs.

• Works closely with RAM Business Analyst and Manager to identify at risk members for engagement in Medicare Advantage/ Commercial risk adjusted markets.

• Provide onsite visits to provider office to educate physician or office staff on appropriate documentation and coding opportunities for risk adjustment.

• Deploys clinical engagement strategy to integrate clinical insights from multiple information sources, including RAM, member outreach calls, provider offices or retail pharmacies.

• Develops & expands member outreach initiatives to eligible members, including driving potential physician or pharmacy visits.

• Assesses member's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to member-s needs and aligned with benefit structure, and develops, coordinates and assists in implementation of individualized plan of care for members.

• Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided. Coordinates with members, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome.

• Develops, coordinates and assists in implementation of individualized plan of care for members.

• Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care including transitional care and communicates with multi-disciplinary teams striving for continuity and efficiency while managing the member along the continuum of care.

• Monitors member's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness.

• Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided.

• Documents accurately and comprehensively based on the standards of practice and current organization policies.

• Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.

• Monitors member's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness.

• Performs other duties as assigned by management.

Disclaimer:
This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Education/Experience:

• High School Diploma/GED required.

• Bachelor’s degree in nursing preferred or relevant experience in lieu of degree.

• Requires a minimum of two (2) years' experience in the health care delivery sy