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RN – Clinical Member Health Advocate

Common Ground Healthcare Cooperative (CGHC) is a nonprofit, community-owned health insurance company well positioned to grow into a major force for positive change in the Wisconsin health insurance market.  We are a member-governed cooperative with a mission to provide affordable, innovative health insurance solutions to small businesses, non-profits and individuals in Wisconsin.  CGHC is looking for a RN – Clinical Member Health Advocate who believes in our mission, is comfortable working in an exciting, fast-paced environment and who is compatible with our team of hardworking, fun and committed staff.

Position Summary:
The RN – Clinical Member Health Advocate serves as an expert consultant to CGHC staff and is an advocate for members to optimize their health and the collective value of health services from the CGHC provider network. The nurse uses clinical experience and skills in a collaborative process to asses, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members; consults and lends expertise to internal and external constituents in the coordination and administration of quality benefit utilization, provides clinical medical review and expertise on grievance cases, and provides recommendations on policies, procedures and appropriate clinical criteria/guidelines for members along the continuum of care; works closely with physician on staff when determinations cannot be completed at the nurse level.

Essential Duties, Responsibilities   

  • Participates on the Appeals and Grievances Committee;
  • Coordinates the out of network referral process with providers, members and outside vendors;
  • Coordinates medical reviews with outside vendors;
  • Serves as CGHC clinical point of contact with members (and/or their designated representative such as a POA) and performs regular outreach to members regarding the provision of medical care and application of benefits;
  • Counsels members on potential treatment options to discuss with their provider (shared decision making model);
  • Advises members regarding programs offerings such as Case Management or Disease Management and works with medical management vendor to make referrals when appropriate;
  • Builds relationships with provider partners and engages in regular discussions regarding patient issues and gaps in cap;
  • Supports efforts related to the Risk Adjustment program;
  • Supports efforts related to medical management and cost containment;
  • Supports efforts related to HEDIS, QHP-EES, and QRS Star ratings;
  • Any other task or duty as assigned or required.

Knowledge and Skill Requirements

  • Active, unrestricted RN License in the State of WI; BSN with advanced degree preferred.
  • 5+ years of experience in at least one of the following: quality improvement, practice management, medical management, health care analytics, managed care contracting OR experience in a primary care or multi-specialty practice that has successfully implemented PCMH, CI or ACO programs or quality improvement initiatives
  • Experience working with and collaborating successfully with senior level leadership; experienced in preparing and presenting information to clinical and executive level leadership
  • Highly developed emotional intelligence, leadership and collaboration skills
  • In-depth knowledge of healthcare management, managed-care, and population health
  • Highly developed critical thinking, problem-solving, and organizational skills
  • Experience with systems and process design/implementation/evaluation
  • Experience with using analytics and information technology to advance programmatic design
  • Experience evaluating and modifying programmatic approaches to population health problems
  • Skilled communicator with individuals and groups (verbal, writing, and presentation)
  • Knows how to build and manage effective teams
  • Strong Microsoft Office Skills with Word, Excel, Outlook and PowerPoint

General Requirements

  • Maintain attendance according to Company standards
  • Adhere to Company policies and procedures
  • Abide by all requirements of the Health Insurance Portability and Accountability Act (HIPAA) and maintain patient, employee, and proprietary confidentiality
  • Ability to treat others with dignity, respect, and courtesy
  • Ability to provide professional image and act professionally
  •  Ability to be flexible and adapt to changing situation
  • Effective verbal and written communication skills
  • Ability to multi-task and work in a fast-paced environment
  • Ability to consistently meet or exceed member expectations in performing own work, and to follow operating procedures and practices to ensure the highest level of patient/ member safety and care
  • Ability to use effective customer service techniques and effective interpersonal skills required
  • Ability to lead with integrity, humility, strategic vision, curiosity, and discipline
  • Ability to work and problem solve independently as well as an integral part of a team
  • Ability to learn new information and integrate processes

Physical Demands and Work Environment
Reasonable accommodation can be made to enable people with disabilities to perform the described essential functions.  This position operates in a fast paced business office setting.  This role routinely uses standard office equipment, including computers, phones, headsets, photocopiers, and fax machines.  While performing the duties of this job, the individual is regularly required to talk, hear, stand, and walk.

Join a winning team of committed professionals in a growing enterprise.  Qualified applicants should send their cover letter, resume and salary requirements to or Common Ground Healthcare Cooperative, Attn:  Human Resources, 120 Bishop’s Way, Suite 150, Brookfield, WI  53005.