Especialista de Plan de Cuidado Individual (No Clinico)

Regular

Exempt

GENERAL DESCRIPTION:

Responsible for the development of interventions and processes for the creation of individualized care plans and registration in the clinical record (CCMS/TruCare) to meet the requirements established in the Model of Care (MOC) for chronic conditions (C-SNP), dual eligibility (D-SNP) and other HRA related processes. Contacts members by phone to update the goals of the established care plan. Documents members’ progress on the clinical platform. Provides education to members regarding preventive testing, medication adherence, treatments, conditions, and other related areas as applicable.

ESSENTIAL FUNCTIONS:

• Monitors interdepartmental operational processes to ensure that they are compliant with the generation of care plans (Models of Care - MOC) as required for the different initiatives within the plans.
• Updates information in reporting tools and/or systems based on clinical recommendations ensuring the performance and quality of the reporting tools and/or systems.
• Performs detailed file and sample-case validation processes before generating care plans to ensure data integrity, correct generation, and compliance with regulations.
• Reviews information from data collection tools for generating care plans.
• Proactively communicates findings from issued reports to appropriate departments within the company so they can make proactive determinations about them.
• Analyzes, reconciles, and reviews the process of depositing the images corresponding to the care plans sent by the external providers.
• Reviews the process of recording standardized notes of interventions in the clinical record (CCMS/TruCare) in agreement with other departments.
• Facilitates processes with the appropriate area to ensure that care plan submissions and targeted interventions are met to encourage compliance with goals following the established criteria.
• Completes operational reports for the monitoring of the care plan generation process.
• Contacts members by phone to update their individualized care plan goals.
• Manages issues raised by the members during the phone call to the corresponding area and provides follow-up until resolved.
• Documents the progress of care plan goals and all steps taken according to the policies and procedures established in the unit in the TruCare clinical platform.
• Educates members on preventive testing, medication adherence, treatments, conditions, and other related areas to maximize resources and decrease utilization.
• Establishes communication with physicians to share relevant information on care plan progress and/or obtain information to update the care plan.
• Participates in preparing the quarterly presentation of metrics on care plan generation.
• Identifies areas of opportunity to improve operational processes related to generating care plans and the registry of interventions.
• Participates in the coordination of the annual process of revising documents related to the care plan generation process following changes to the (Models of Care - MOC), policies and procedures, and/or new Medicare regulations.
• Develops reports and briefings as required in the operational area.
• Complies fully and consistently with company standards, policies, procedures, and local and federal laws applicable to our industry, business, code of conduct, and employment practices.

MINIMUM QUALIFICATIONS:

Education: Bachelor’s degree in Health Education or related field.

Experience: Minimum of three (3) years of experience in analyzing, implementing, and evaluating educational programs.

Certifications / Licenses: N/A

“Proven experience may be replaced by previously established requirements.”

Other: Advanced knowledge of Access and Excel is required. Knowledge of analysis and management of tables and relationships in databases.

Languages:
Spanish – Advanced (writing, conversation, and comprehension)
English – Intermediate (writing, conversation, and comprehension)

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