Ncqa Jobs in Reno, NV (NOW HIRING)

Responsibilities
Prominence Health is a value-based care organization bridging the gap between affiliated health systems and independent providers, building trust and collaboration between the two. Prominence Health creates value for populations and providers to strengthen integrated partnership, advance market opportunities, and improve outcomes for our patients and members. Founded in 1993, Prominence Health started as a health maintenance organization (HMO) and was acquired by a subsidiary of Universal Health Services, Inc. (UHS) in 2014. Prominence Health serves members, physicians, and health systems across Medicare, Medicare Advantage, Accountable Care Organizations, and commercial payer partnerships. Prominence Health is committed to transforming healthcare delivery by improving health outcomes while controlling costs and enhancing the patient experience.
Learn more at: https://prominence-health.com/
Job Summary:
Under the supervision of the Transition of Care Clinical Program Manager, The Transition of Care (TOC) Nurse is responsible for managing a member's successful transition from an acute or post-acute level of care to home and is accountable for developing, implementing, and evaluating comprehensive transitional care interventions for high risk medical and/or surgical members for Prominence Health. He/she is responsible for facilitating the post-acute care of members that are at risk for poor health outcomes, frequent emergency room visits, and hospital readmissions.
The TOC nurse identifies hospitalized high-risk, complex members for program enrollment and communicates with all entities involved in the care of the member to promote and maximize care coordination. Key aspects of the TOC Program protocols are based upon inpatient and post-discharge workflows. Inpatient/SNF workflow includes visiting members at the bedside, member and family education regarding disease states and self-care, identification of member-level concerns regarding discharge, and anticipation of potential gaps in care. The inpatient/SNF encounters are designed to educate members/caregivers surrounding their post discharge health care needs and to empower them to play an active and informed role in managing their care post-discharge.
Upon member hospital/SNF discharge, the post-discharge workflow includes a scheduled periodic telephonic follow-up for 30 days and an in person visit, when appropriate. This includes a focus on medication reconciliation and adherence, management of member's quality of life and functionality, management of both acute and chronic disease states, identification and rectifying gaps in care, support of member's ability to perform self-cares, coordination of post-discharge appointments and services (durable medical equipment, home health), and coordination of care across the care continuum.
The TOC Nurse will adhere to the CMSA Standards of Practice for Case Management. The TOC Nurse refers and contributes to the development of the plan of care of members in Care Management. Additionally, the position participates in efforts associated with the successful operation of the SNP CM program and that the model of care (MOC) meets or exceeds regulatory and accreditation requirements for the Centers for Medicare and Medicaid Services (CMS), state Medicaid offices (as relevant), and NCQA.
*Hybrid Friday-Tuesday (Sat/Sun required, in-person visits on weekends). Wed/Thus off.
Benefit Highlights:

• Loan Forgiveness Program
• Challenging and rewarding work environment
• Competitive Compensation & Generous Paid Time Off
• Excellent Medical, Dental, Vision and Prescription Drug Plans
• 401(K) with company match and discounted stock plan
• SoFi Student Loan Refinancing Program
• Career development opportunities within UHS and its 300+ Subsidiaries! • More information is available on our Benefits Guest Website: benefits.uhsguest.com

About Universal Health Services:
One of the nation's largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. During the year, UHS was again recognized as one of the World's Most Admired Companies by Fortune; and listed in Forbes ranking of America's Largest Public Companies. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com
Qualifications
Qualifications and Requirements:
Education:

• Associate or Bachelor's Degree in Nursing , required .

License & Certifications:

• Active, unrestricted, current, and valid Registered Nurse licenses in the States of Practice (Nevada, Texas and/or Florida), required.
• Certified Case Manager (CCM), C ase Management Nurse - Board Certified (CMGT-BC), Accredited Case Manager - RN (ACM-RN), or Certified Managed Care Nurse (CMCN), preferred.

Experience:

• Minimum of three (3) years in clinical nursing practice, required .
• Minimum of three (3) years of Case Management/Transition of Care experience in a managed care outpatient or community environment, preferred.
• Recent working knowledge of Milliman Care Guidelines, preferred.
• Experience working with the Medicare and Medicaid population segment, preferred.
• Knowledge of Medicare / Medicaid processes and compliance standards, preferred.
• Ability to effectively communicate in English (Nevada, Texas, and Florida markets). Preferred Spanish (Texas and Florida markets), and/or Spanish, French Creole, and/or Tagalog (Florida market), both verbally and in writing depending on the State of RN licensure and employment location, preferred .

*Hybrid Friday-Tuesday (Sat/Sun required, in-person visits on weekends). Wed/Thus off.
EEO Statement
All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.
We believe that diversity and inclusion among our teammates is critical to our success.
Avoid and Report Recruitment Scams
At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS
and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc.
If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.