This position will conduct clinical member outreach calls as well as take inbound calls as it relates to all Quality Outreach Initiatives. This positon will focus on members with HEDIS and Star care gaps that are high risk for non-compliance and will assist the member in eliminating barriers and close care gaps.

Responsibilities:
1. Receives incoming calls from members emanating from quality outreach initiatives such as mailings, emails, phone calls, etc.

2. Makes outgoing calls to educate members on the importance of closing gaps in care such as appropriate testing, periodical checkups, immunizations, counseling and provide health education materials.

3. Maintain accurate member records from outreaches such as incoming calls, successful outreaches, member issues, and member roadblocks.

4. Act as a liaison with providers, members and outside community resources by assisting with scheduling an appointment, warm transfers to member services, etc.

5. Assure understanding level of each member by providing clear and complete information in accordance with company guidelines.

6. Refer members to a Clinical Quality nurses as necessary.

The information above is intended to describe the general nature of the work being performed by each incumbent assigned to this position. This job description is not designed to be an exhaustive list of all responsibilities, duties, and skills required of each incumbent.


Qualifications:
Education/Experience:

1. Requires an Associates degree from an accredited college or university, preferably in healthcare field. In lieu of degree applicant must have 3 years of equivalent and relevant work experience.
2. Requires 2 years work experience in case management, community health, Medicaid or health insurance environment.
3. Requires a minimum of 2 years experience working with members to close gaps in care.
4. Requires a minimum of 1 year managed care experience.


Knowledge:

1. Requires knowledge of the Managed Care or Health Insurance Industry.
2. Requires knowledge of medical terminology.
3. Requires knowledge of PC's and windows based software applications.
4. Prefer knowledge of Medicaid and Medicare regulations.

Skills and Abilities:
1. Requires excellent verbal and written communication skills.
2. Requires excellent service quality skills.
3. Requires excellent organizational and interpersonal skills.
4. Requires good decision making skills.
5.Requires good problem solving/conflict resolution skills.
6.Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint); Should be knowledgeable in the use of intranet and internet applications.