Mount Sinai and Bright Health have formed a strategic partnership to offer co-branded Medicare Advantage plans effective January 1, 2019 in New York, Kings and Queens counties. Mount Sinai’s hospitals and physicians represent the core of the provider network for the co-branded plans. The plans include both individual Medicare Advantage plans (MAPD) as well as an individual dual eligible special needs plan (D-SNP) for seniors eligible for both Medicare and Medicaid.
The Market Clinical Program Lead will be a registered nurse supporting key population health activities for the newly formed partnership. This lead will leverage various tools and personnel to ensure appropriate cost containment, quality standards, and risk assessments are completed and desired health outcomes are achieved for Bright Health members. While the Market Clinical Program Lead will be embedded within Mount Sinai clinical operations, they will serve as the primary liaison between Mount Sinai and Bright to ensure Bright Health members are being properly managed.
The Market Clinical Program Lead will be initially responsible for the following tasks with the expectation that as the partnership and program grows, there will be additional responsibilities identified for the Market Clinical Program Lead .
· Supports and acts as liaison with the payer, providers, and patients and serve as the primary patient information resource for payers.
· Leads the advancement and integration of quality assessment and quality performance improvement strategies for Bright Health Medicare products in collaboration with senior leadership and service delivery management.
· Develops, implements and refines quality and safety programs at the inter-professional level through consultation, program activities and collaboration across operations
· Builds shared vision to incorporate a culture that is data driven and aligns with evidenced based best practices that are compliant with CMS and NYS DOH requirements.
· QA nurses collaborate with physicians and treatment teams to develop patient-care guidelines and serve on quality-improvement teams.
· Leads special initiatives and ongoing efforts in areas of quality assessment and practice improvement. Facilitates and supports operational changes and activities which further quality improvement and clinical staff development goals.
· Provide ongoing support relative to HEDIS data extraction, data collection and validation
· Assist in coordination of outreach efforts to request, collect, and secure clinical documentation
· Review assigned medical records in order to abstract specified and required clinical data elements
· Develop an understanding of Bright Health’s population health, network keepage, risk, and quality strategies to effective manage the member population.
· Utilize a variety of internal and external tools to orchestrate a coordinated workflow that equally prioritizes the care of the member, Bright Health’s mission, and the care partner.
· Facilitate nomination of members to case management and disease management programs. Provide collaborative support to market team/care partner on strategies to improve these processes.
· Effectively launch collaborative market initiatives.
· Provide surveillance of high-risk members, tracking, and trending outcomes of CM/CCM activities
· Lead market activities to achieve Bright Health’s and Mount Sinai’s joint strategy for quality and risk; network boundary management; and utilization.
· Support quality and risk process by working with internal teams and collaborating with care partner to request, review, and abstract medical records for HEDIS, quality of care concerns, quality improvement programs, and care coordination, including electronic and paper medical records.
· Ability to thrive in the excitement and fast paced environment of a rapidly growing organization.
· Willingness to think creatively and solve problems.
Skills: Clinical problem solving: technical capability including proficiency within Microsoft office suite, using EMRs, navigating a variety of reports; relationship building; ability to influence without authority; understanding population health management methodology.
· You are a nurse by training with a current and active RN license.
· You have 2+ years of experience in clinical quality initiatives.
· You have 2+ years of hands-on clinical experience or have also worked in Managed Care.
· You've experienced or are excited to learn the in's and out's of health plan operations.
· You have excellent communication skills and feel comfortable delivering professional presentations to an audience.
· You have experience working in a health plan/payer setting.