United States onlyThe Clinical Care Analyst plays a pivotal role in our Transition of Care program and reducing unnecessary utilization in our high priority members at Healthmap Solutions. The role is accountable for developing, implementing, and evaluating comprehensive transition care interventions and opportunities to reduce cost of care for our high priority members. This position partners with our regional care navigation model to positively impact the clinical outcomes of the Kidney Health management population.Responsibilities:
- Analyze data and reports to identify Healthmap Solutions members that would benefit from care navigation support to reduce inappropriate utilization patterns to improve member health outcomes and reduce cost of care
- Document clinical and, if appropriate, Social Determinants of Health (SDoH), summary of the high-cost and/or high-utilization
- Develop and provide structured action steps for the Clinical Community Liaison, Care Navigators, and Quality Practice Advisors, etc. by utilizing critical thinking skills, clinical assessment skills and acquired knowledge
- Understand Clinical Review such as medical necessity, Utilization Review/Management, HEDIS, Chart Auditing, Medical Records Reviews
- Working knowledge of cost of care and impact of readmissions
- Understand department, segment, and organizational strategy and operating objectives, including their linkages to related areas
- Active participant in evaluating the High-cost/High-utilizer and Transition of Care strategies
- Document in Electronic Medical Records (EMR) and various technology platforms with accuracy and high-level proficiency to ensure analytics cover components needed for required responsibilities
- Ensure timely and successful delivery of reports
- Perform other duties as assigned
- Bachelor’s degree in nursing required
- Active, unrestricted RN license required; compact and/or multi-licensed preferred
- 5 years of progressive experience in healthcare services, clinical operations, quality, or care management
- 3 + years of clinical experience within any healthcare setting {Acute Care, Outpatient, etc.}
- Experience with of cost of care initiatives that decrease admissions and readmissions
- Certified Case Management (CCM) preferred
- Able to identify variances surrounding HCPCs, CPTs, ICD-10 preferred
- Experience with Medicare and Medicaid preferred
- Residence in assigned state
- Excellent verbal, written, listening and presentation skills
- Ability to show compassion and empathy for patients
- Demonstrated interpersonal relationship skills that drive collaboration toward organizational goals
- Ability to multitask, prioritize, and create solutions in a fast-paced environment
- Strong critical thinking and analytical skills
- Must be proficient in Microsoft Office: Outlook, Word, Excel, PowerPoint
