Medicare Programs Clinical Lead
San Diego, California
You'll be the model-of-care expert and train plan providers and provider groups on delivering it.
- Eligibility
- Administrative & Consulting Nurses
- Shift and hours
- 8-hour day shifts · Day shifts Shift: 8 Hours - Day Shifts40 hours a week
- Unit and setting
- Case Management
- License
- RN license Unencumbered RN license where you practice, or multistate licensure in an NLC state
- Term
- Permanent Job Schedule: Full timeFull time
Do you qualify?
- License
- Unencumbered RN license where you practice, or multistate licensure in an NLC state Check your license
- Certification
- Department-specific competencies and certifications, kept current Obtains and subsequently maintains required department specific competencies and certifications.
- Education
- Bachelor's degree in nursing Bachelor’s degree in nursing required.
- Experience
- Five years of nursing experience Minimum of five years of nursing experience.
- Also asks
- Proficient in Epic, Care Coach, Point Click Care, Word and Excel Must be proficient in computer software such as Epic, Care Coach, Point Click Care, Word and Excel.
Preferred
- Education
- Graduate of a nationally accredited nursing program (CCNE, ACEN or NLN CNEA)
- Experience
- Quality, medical coding, or risk adjustment experience Quality, medical coding, and/or risk adjustment experience is preferred.
- Also asks
- Knowledge of accreditation and regulatory agency standards Experience and knowledge of accreditation and regulatory agency standards preferred.
What it pays
- Against similar roles
- Below most San Diego staff RN postingsSan Diego staff RN postings that state pay run $39/hr to $64/hr, the middle half $42/hr to $60/hr, across 119 postings.
Benefits
- BenefitsHealth insurance
- BenefitsDental insurance
- BenefitsVision insurance
- BenefitsLife insurance
- Benefits401(k) retirement plan
- BenefitsWork/life balance benefits
More benefits (3)
- BenefitsA generous time off package
- Generous time off package
- PTO
The role and schedule
- Charting
- Epic, Care Coach and PointClickCare software
- Day to day
- HEDIS gap assessments, and getting providers to close the gaps Completes gap assessment of healthcare effectiveness data and HEDIS measures and ensures providers are equipped to close remaining HEDIS gaps.
- Day to day
- Coaching providers and doing their chart reviews
- Day to day
- Reviewing member risk scores for missing diagnoses Analyzes member risk score data and determines members that may not have all active diagnoses captured.
- Day to day
- Overseeing the annual chart review and the vendors who handle it
- Day to day
- Building and maintaining CCIP and quality improvement projects Develops, implements, and maintains a CCIP and Quality Improvement Projects (QIP).
- Details
- Remote job, on Central Time Facility: Remote SD (Central Time)
The workplace
Ask Mira
Your fit
Questions to ask
- Can you walk me through base pay range and differentials?
- What should I expect for weekend, holiday, call, and rotation?
- What orientation, preceptor time, and ongoing unit support are included?
- How are patient load, floating, and staffing support handled day to day?
Original listing
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Leads clinical operations of Medicare programs with a primary focus in model of care development and delivery, healthcare effectiveness data and information set (HEDIS), Medicare star rating, Chronic Care Improvement (CCIP) and risk adjustment. Works closely with Sanford leadership and provider groups to ensure the model of care is carried out to members consistently and meets regulatory requirements. Assumes the role as subject matter expert on the model of care and super trainer on the delivery of that model of care to plan providers and provider groups.
Develops, implements, and maintains a CCIP and Quality Improvement Projects (QIP). Participates in the quality improvement committee(s) established as a result of participation in Medicare programs. Completes gap assessment of healthcare effectiveness data and HEDIS measures and ensures providers are equipped to close remaining HEDIS gaps.
Monitors star ratings and formulates action plans to achieve a four star or above rating.
What's around it?
San Diego, CAFrom Census ACS 2024.
Living costs about 12% above the US average
- Median rent
- $2,313/mo
- Household income
- $108,077/yr, all local households, not nurse pay