JOB SUMMARY

Responsible for generating and develop strong relationships, identifying new opportunities for partnering and growth. Performs MRR to primary care physicians, PMG, participating providers and facilities to determine the level of compliance with medical guidelines, indicators for staying healthy, not limited to screenings, tests, and vaccines, managing chronic conditions and all HEDIS indicators. Monitors primary medical group compliance with performance measures and implements strategies within the group for improvement of the measures, includes encounter data submission, Health Risk Evaluation Form (E-pass), Stars indicators, MLR assessment. Accurate documentation of diagnosis. Responsible for the analysis, interpretation and presentation of the audits results with the providers. Develops, coordinates and implements corrective action plan and follow up with these providers.

ESSENTIAL FUNCTIONS

• Provides complex care planning to high-risk patients in the community, meeting with them face to face before, during, or after PCP visits, according to established program protocols and policies.
• Accepts responsibility for patients’ Transitions of Care, coordinating provisions for discharge from facilities including follow-up appointments, home health, social services, transportation, etc., in order to maintain continuity of care.
• Conduct follow-up telephonic care calls to patients and families, if required.
• Reviews /triages PCP referrals to determine program and service needs of patients referred.
• Implements POC in accordance with established policies, prioritizing patient care needs and meeting with patients, patients’ family and caregivers as needed to discuss care and treatment plan.
• Consults regularly with the PCP, Care Point Medical Director, Pharmacist, and other team members to ensure that the POC remains relevant, appropriate, and responsive to changing patient status and, or goals.
• Leverages all available patient information available, including but not limited to PCP and hospital EMRs, Triple S Database and the Portal.
• Conducts on-site or telephonic prospective, concurrent, and retrospective review of active patient care to evaluate goal progression and timely discharge, when appropriate.
• Participates actively in clinical rounds and, or case review meetings with Care Point Medical Director, reviewing panel of high-risk patients, including prospective and newly enrolled patients.
• Maintains accurate and complete records, documents all care rendered, pertinent patient information, all communications, and all care management decisions in appropriate databases of Care Point.
• Initiates and oversees data entry into IS systems of all patients within the parameters of care management policies and procedures.
• Provides accurate information to patients and families regarding community resources, referrals, and other related issues.
• Uses, protects, and discloses Care Point patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.

EDUCATION

EXPERIENCE

• Bachelor’s Degree in Nursing with one (1) to three (3) years of experience in Coordinated Care, preferably.
• Current/ valid license in Puerto Rico Register Nurse without restrictions. Member of College of Nursing Professional of Puerto Rico.

LICENSES AND CERTIFICATIONS

COMPETENCIES