Clinical - Patient Care Advocate - 730650

Job Profile Summary
Position Purpose:
Works with members and providers to close care gaps, ensure barriers to care are removed, and improve the overall member and provider experience through outreach and face-to-face interaction with members and providers at large IPA and/or group practices. Serves to collaborate with providers in the field, to improve HEDIS measures and provides education for HEDIS measures and coding. 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.

Education/Experience:
Required: a Bachelor's Degree in Healthcare, Public Health, Nursing, Psychology, Social Work, Health Administration, or related health field or equivalent work experience required (a total of 4 years of experience required for the position); work experience should be in direct patient care, social work, quality improvement or health coaching preferably in a managed care environment. 2+ years of experience work experience should be in direct patient care, social work, quality improvement or health coaching preferably in a managed care environment.

License/Certification: One of the following is preferred. Licensed Practical Nurse (LPN); Licensed Master Social Work (LMSW); Certified Social Worker (C-SW); Licensed Social Worker (LSW); Licensed Registered Nurse (RN) preferred.

Responsibilities
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

EEO:

Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.

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Job Profile Summary Position Purpose: Works with members and providers to close care gaps, ensure barriers to care are removed, and improve the overall member and provider experience through outreach and face-to-face interaction with members and providers at large IPA and/or group practices. Serves to collaborate with providers in the field, to improve HEDIS measures and provides education for HEDIS measures and coding. 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. Education/Experience: Required: a Bachelor's Degree in Healthcare, Public Health, Nursing, Psychology, Social Work, Health Administration, or related health field or equivalent work experience required (a total of 4 years of experience required for the position); work experience should be in direct patient care, social work, quality improvement or health coaching preferably in a managed care environment. 2+ years of experience work experience should be in direct patient care, social work, quality improvement or health coaching preferably in a managed care environment. License/Certification: One of the following is preferred. Licensed Practical Nurse (LPN); Licensed Master Social Work (LMSW); Certified Social Worker (C-SW); Licensed Social Worker (LSW); Licensed Registered Nurse (RN) preferred. Responsibilities 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
Story Behind the Need
Our team is focused on three core initiatives: improving HEDIS performance, strengthening provider partnerships, and enhancing the member experience by reducing barriers to care. We are targeting high-impact preventive and chronic care measures to drive measurable year-over-year improvement. This role is essential in turning strategy into action. By conducting outreach, closing care gaps in real time, and addressing member barriers like transportation, the individual directly drives quality outcomes, improves provider performance, and enhances trust with members and practices. Delaware First Health has a high volume of members with open care gaps who need targeted outreach to schedule appointments. These positions will fulfill that need. The team culture and work environment is a flexible, collaborative environment that will allow these candidates to work independently while also driving meaningful health outcomes for our members. Yes. I will be submitting an additional request for 5 temps to embed in provider practices.
Typical Day in the Role
Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD). What are performance expectations/metrics? What makes this role unique?	- Conducts telephonic outreach to members and coordinates with the provider community to schedule routine appointments (Annual Preventive Visits, Diabetic Eye Exams, Mammograms, Colonoscopies, etc.) - Educates members on the importance of routine screenings. - Research member claims, care gaps, and outreach history prior to conducting outbound calls. - Assists members with wraparound services such as translation, transportation, or referrals for other value-added benefits as needed. - Document outreach outcomes within designated tools. - Performance metrics: Members reached/engaged, Appointments Scheduled, Care Gaps closed
Candidate Requirements
Required: Bachelor's Degree in Healthcare, Public Health, Nursing, Psychology, Social Work, Health Administration, or related health field or equivalent work experience required (a total of 4 years of experience required for the position)			Preferred:
Required: NA			Preferred: RN, LPN, LMSW, LSW, Certified Social Worker
Years of experience required: 2 years. Work experience should be in direct patient care, social work, quality improvement or health coaching, preferably in a managed care environment. Disqualifiers: Additional qualities to look for: 30-50 inbound and outbound calls per day experience
Top 3 must-have hard skills stack-ranked by importance	1	Excellent customer service skills
	2	Member and/or patient outreach and care gap closure (telephonic and/or in-person)
	3	Familiarity with Medicaid, Medicare Advantage, or dual populations
Candidate Review & Selection
Shortlisting process Candidate review & selection Interview information Onboard process and expectations	Projected Manager Candidate Review Date:			1-2 days post shortlisting
	Type of Interviews:			Teams camera on
	Required Testing or Assessment (by Vendor):			NA
Next Steps
Do you have any upcoming PTO?	September 11-18, October 7-9, and December 14-18
Colleagues to cc/delegate	Tawonna Ingram, Laura Buvel