Clinical Care Specialist

3 weeks ago

Pittsburgh, Pennsylvania, United States HealthMap Solutions LLC Full time
Job Summary

The Clinical Care Analyst plays a pivotal role in our Transition of Care program, reducing unnecessary utilization in high-priority members at Healthmap Solutions. This role is accountable for developing, implementing, and evaluating comprehensive transition care interventions to reduce cost of care for high-priority members.

Key Responsibilities
  • Analyze data and reports to identify Healthmap Solutions members who would benefit from care navigation support to reduce inappropriate utilization patterns and improve member health outcomes.
  • Document clinical and, if appropriate, Social Determinants of Health (SDoH) summaries of high-cost and/or high-utilization members.
  • Develop and provide structured action steps for the Clinical Community Liaison, Care Navigators, and Quality Practice Advisors, utilizing critical thinking skills, clinical assessment skills, and acquired knowledge.
  • Understand Clinical Review, including 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.
Requirements
  • 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 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.
Skills
  • 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.

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