Patient Care Advocate

Position: Patient Care Advocate

Location: Newark New Jersey (Hybrid Role)

Duration:3 Months (Possible Extension)

Shift: 95 Hybrid position working with providers throughout the State of NJ as needed.

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 facetoface 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.
• Assists 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 providers office for medical appointments.
• Schedules doctor appointments on behalf of the practitioner and assists member with wraparound services such as arranging transportation connecting them with communitybased resources and other affinity programs as available.
• Maintains confidentiality of business and protects health information.
• Walk me through the daytoday responsibilities of this the role and a description of the project.
• Conduct member and Provider outreach (virtual phone or in person).
• Education on care gaps and assist with scheduling appointments and/ or transportation.
• Describe the performance expectations/metrics for this individual and their team:
• Member outreach calls < 70 calls a day.
• Positive and collaborative engagement with members and providers.
• Identify and assist with all discovered barriers find a provider/ transportation etc.
• Escalation of referrals to CM and other appropriate departments.

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 educates Provider practices in appropriate HEDIS measures and HEDIS ICD10 /CPT coding in accordance with NCQA requirements.
• Assesses provider performance data to identify and strategize opportunities for provider improvement.
• Collaborates with Provider Relations to improve provider performance in areas of Quality Risk Adjustment 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 providers office.
• Conducts facetoface education with the members and their family in the providers 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.
• Arranges transportation and followup appointments for members as needed.
• Documents all actions taken regarding contact related to member.
• 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 A Bachelors Degree in Healthcare Public Health Nursing psychology Social Work Health Administration or related health field or equivalent work experience required. (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 work experience should be in direct patient care social work quality improvement or health coaching preferably in a managed care environment.

License/Certification:
One of the following is preferred:

• Licensed Practical Nurse (LPN)
• Licensed Master Social Work (LMSW)
• Certified Social Worker (CSW)
• Licensed Social Worker (LSW)
• Licensed Registered Nurse (RN) preferred.