Pittsburgh, United States

Full-Time

Position Summary:

The Clinical Care Analyst plays a pivotal role in our Transition of Care program and reducing necessary utilization in our high priority members at Healthmap Solutions. The role is accountable for developing, implementing, and evaluating comprehensive transition care interventions and opportunities to reduce cost of care for our high priority members. This position partners with our regional care navigation model to positively impact the clinical outcomes of the Kidney Health management population.

Responsibilities:

Analyze data and reports to identify Healthmap Solutions members that would benefit from care navigation support to reduce inappropriate utilization patterns to improve member health outcomes and reduce cost of care
Document clinical and, if appropriate, Social Determinants of Health (SDoH), summary of the high-cost and/or high-utilization
Develop and provide structured action steps for the Clinical Community Liaison, Care Navigators, and Quality Practice Advisors, etc. by utilizing critical thinking skills, clinical assessment skills and acquired knowledge
Understand Clinical Review such as medical necessity, Utilization Review/Management, HEDIS, Chart Auditing, Medical Records Reviews
Working knowledge of cost of care and impact of readmissions
Understand department, segment, and organizational strategy and operating objectives, including their linkages to related areas
Active participant in evaluating the High-cost/High-utilizer and Transition of Care strategies
Document in Electronic Medical Records (EMR) and various technology platforms with accuracy and high-level proficiency to ensure analytics cover components needed for required responsibilities
Ensure timely and successful delivery of reports
Perform other duties as assigned

Requirements:

Bachelor’s degree in nursing required
Active, unrestricted RN license required; compact and/or multi-licensed preferred
5 years of progressive experience in healthcare services, clinical operations, quality, or care management
3 + years of clinical experience within any healthcare setting {Acute Care, Outpatient, etc.}
Experience with of cost of care initiatives that decrease admissions and readmissions
Certified Case Management (CCM) preferred
Able to identify variances surrounding HCPCs, CPTs, ICD-10 preferred
Experience with Medicare and Medicaid preferred
Residence in assigned state

Skills:

Excellent verbal, written, listening and presentation skills
Ability to show compassion and empathy for patients
Demonstrated interpersonal relationship skills that drive collaboration toward organizational goals
Ability to multitask, prioritize, and create solutions in a fast-paced environment
Strong critical thinking and analytical skills
Must be proficient in Microsoft Office: Outlook, Word, Excel, PowerPoint

Travel:

Limited Travel, scheduled per needs of the business

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