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About the Role
Works with members and providers to close care gaps, remove barriers to care, and improve member and provider experience through outreach and face-to-face interaction. Serves to collaborate with providers to improve HEDIS measures and provides education for HEDIS measures and coding.
Responsibilities
- 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 community-based resources and other affinity programs as available.
- Maintains confidentiality of business and protected health information.
- 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 ICD-10 /CPT coding in accordance with NCQA requirements.
- Assesses provider performance data to identify and strategizes 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 provider’s office.
- Conducts face-to-face education with the member and their family, in the provider’s 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 follow-up appointments for member 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.
- Performs other duties as assigned.
- Complies with all policies and standards.
Requirements
- Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future.
- Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT.
Skills
- Direct patient care
- Social work
- Quality improvement
- Health coaching
- Managed care environment
- HEDIS measures
- HEDIS coding
- NCQA requirements
- Risk Adjustment
- Claims
- Encounters
Location
- Austin, Texas
- San Antonio, Texas
Work Type
- Hybrid
- Remote
- Local travel
Experience Level
- 4 years of equivalent work experience
- 2+ years of experience in direct patient care, social work, quality improvement or health coaching preferably in a managed care environment
Education Level
- Bachelor's Degree in Healthcare, Public Health, Nursing, Psychology, Social Work, Health Administration, or related health field
- Licensed Practical Nurse (LPN)
- Licensed Master Social Work (LMSW)
- Certified Social Worker (C-SW)
- Licensed Social Worker (LSW)
- Licensed Registered Nurse (RN)
Salary/Compensations
- $27.02 - $48.55 per hour
Benefits
- Competitive pay
- Health insurance
- 401K
- Stock purchase plans
- Tuition reimbursement
- Paid time off plus holidays
- Flexible approach to work
About the Company
- At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day.
- You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective.
- It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.
Equal Opportunity
- Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different.
- All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
- Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.