Major Responsibilities:

Develops, implements and maintains efficient processes to evaluate and analyze information from various databases to identify, triage and refer cases for various levels of care management throughout the AAH system (Disease Management, On-site Nurse Case Management, Catastrophic Case Management, Teleservices, Ambulatory Care Management, Care Transitions etc.) Develops and distributes related reports.Develops, implements and maintains efficient processes to evaluate and analyze information gathered from various databases to create regular and ad hoc reports regarding outcomes and opportunities for Disease Management, On-site Nurse Case Management, Catastrophic Case Management, Ambulatory Care Management and Care Transitions.Develops and deploys outreach strategies for members and providers which identify care gaps and encourage action.Facilitates/leads interdisciplinary team(s) to develop clinical profiles within Epic/Cogito/Radar. Members of the disciplinary team(s) will include medical directors, outside nurse case managers, catastrophic case managers, case managers, disease management representatives, teleservices representatives and management representatives.Implements and develops databases as necessary in order to obtain pertinent data. Collaborates with operational areas to identify data collection gaps.Acts as liaison with Information Technology, On-site Nurse Case Management, Clinical Decision Support, Clinical Improvement, Ambulatory Care Management, Care Transitions and Teleservices to coordinate, implement and integrate work products. Works with Clinical Decision Support and Clinical Improvement to assess, measure, and report on quality management and care management initiatives.Works with IS, software vendors and payers to insure accuracy and integrity of data.Analyzes trends and events to support the strategic objectives, measurements and intervention planning for NCQA.Collaborates with manager in the development and maintenance of policies, procedures and performance standards related to this role. Maintains current knowledge of contracts, departmental/organizational policies and procedures and NCQA standards.Attends and actively participates in appropriate meetings including staff meetings, process improvement meetings and those meetings required by the organization. Keeps abreast of organizational and industry issues and changes as they pertain to this role.

Licensure, Registration, and/or Certification Required:

Registered Nurse license issued by the state in which the team member practices.

Education Required:

Bachelor's Degree (or equivalent knowledge) in Nursing, orBachelor's Degree in Business or related field.

Experience Required:

Typically requires 5 years of experience in case management, utilization review, managed care, healthcare quality, and 3 years of clinical experience.Knowledge of HEDIS and Quality measures, project management experience, a high level of data analysis skills, and excellent time managements skills to execute outreach campaigns.

Knowledge, Skills & Abilities Required:

High level of analytical skills in order to develop, implement and maintain efficient processes relative to the use of various databases to identify opportunities and report outcomes.Excellent computer skills including knowledge of various managed care information systems and demonstrated proficiency in Internet searches and the use of data management tools.Strong skills in the use of windows-based software applications including but not limited to Word, Excel, PowerPoint and Access.Demonstrated knowledge of evolving health care delivery environment.Strong written and verbal communication skills.Must have a strong customer service orientation and is a self-directed, results oriented problem-solver.Must have excellent interpersonal and negotiation skills.Ability to work well within a team atmosphere while recognizing and meeting the individualized needs of customers and internal partners

Physical Requirements and Working Conditions:

Position requires travel. May be exposed to weather and road hazards.Must have functional speech, vision, smell, touch and hearing.Exposed to normal office environment.Operates all equipment necessary to perform the job.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.