Clinical Program Support Nurse (100% remote)

Job Description

The Clinical Program Support Nurse will play a key role on our clinical program team, offering a unique blend of customer service and clinical expertise to beneficiaries enrolled in Medicare and Commercial plans. The nurse will engage in telephonic calls with plan beneficiaries, providers, pharmacists, and other stakeholders to discuss care gaps and potential solutions, driving outcomes for CMS Stars and HEDIS quality measures. Responsibilities include managing a caseload, analyzing data, and organizing and documenting all relevant interactions.

Responsibilities

• Responsible for member telephonic outreach to enhance medication therapy and drive strategic targeted initiatives forward.
• Conduct clinical outreach to members, prescribers, and pharmacy providers to enhance care coordination.
• Identify potential issues based upon information gathered during the interview with the member.
• Recommend clinical case determinations on a case-by-case basis or escalate to clinical pharmacist for further evaluation.
• Perform all necessary tasks in a platform with optimum quality and efficiency.
• Ensure compliance with CMS guidelines for Medicare Stars programs and cost of care clinical programs.
• Follow HIPAA, privacy, safety, and compliance guidelines.
• Collaborate with team members to maintain clinical program services and exceed program expectations.
• Stay updated on training levels, industry guidelines, literature, recommendations, and medications (prescription and OTC) to ensure program relevance and effectiveness.
• Contribute to the development and implementation of innovative clinical outreach initiatives.
• Follow all established health policies and procedures including but not limited to HIPAA, privacy and security policies and procedures.
• Operate office equipment such as voice mail messaging systems, email, and use of various software applications to support operational processes.
• Perform other duties or tasks, as assigned or required.

Essential Skills

• Case management
• Telephone customer service
• Cardiology
• Graduation from an accredited nursing program (LPN, RN) with an active license
• Current nurse license in good standing with State Board of Nursing
• 1 year of relevant work experience in a clinical and/or managed care setting

Additional Skills & Qualifications

• Ability to work as a team member, be professional and have telephonic communication skills.
• Attention to detail and exercise professional work ethics.
• Intermediate understanding of Microsoft Office Suite (Excel, Word, etc.) and knowledge of efficient record-keeping techniques.
• Intermediate understanding and ability to navigate a database system.
• Excellent written, verbal, and presentation skills with the ability to convey complex ideas to diverse audiences.
• Strong analytical and problem-solving skills with attention to detail and quality.
• Ability to work on multiple projects simultaneously under pressure with strict timelines.
• Ability to develop process efficiencies.
• Must have high-speed internet.
• Experience with CMS Stars and HEDIS quality measures, risk revenue value streams, and population health management.
• 1 year of work experience in clinical, managed care and/or Pharmacy Benefit Management (PBM) setting.
• Experience in health plan provider network performance management, population health management, continuous improvement or provider engagement models.
• English: Required

Work Environment

100% remote. The work schedule is Monday to Friday, 8:30 AM to 5:00 PM EST, with no weekends required. Continuous training is provided, starting with shadowing in the first week, followed by reverse shadowing in the second week, and ongoing monitoring and feedback from the third week onward.