Special Needs Plan Program Specialist

Regular

Exempt

GENERAL DESCRIPTION: Performs health risk assessments (HRA’s) to determine if the member is eligible for Special Supplemental Benefits for the Chronically Ill (SSBCI). Reviews the member's individualized care plan and performs specific interventions to monitor the member's health status.

ESSENTIAL FUNCTIONS:

• Performs Health Risk Assessments for all members referred for Special Supplemental Benefits for the Chronically Ill (SSBCI) within the established time frame.
• Makes telephone calls to the most vulnerable population to monitor the health status and the member's compliance with his or her individualized care plan.
• Alert in case of identifying deficiencies or opportunities for improvement to guarantee the clarity of the processes.
• Contacts members by phone to complete assessments and provide appropriate referrals.
• Contacts physicians to complete member assessments in cases where additional medical information is needed from the member.
• Identifies potential cases for appropriate intervention by the corresponding area.
• Receives and appropriately directs incoming calls from members and physicians.
• Manages any situation from physicians or a member to be promptly referred to complete the Health Risk Assessment.
• Communicates the assessment’s final determination according to departmental policies and procedures and within established time parameters.
• Maintains reports and productivity metrics as requested.
• Complies with production, quality, and timelines as required per applicable regulations.
• Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
• May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

MINIMUM QUALIFICATIONS: Education and Experience: Bachelor of Science in Nursing (BSN). Minimum of three (3) years of experience in clinical areas, including documentation or analysis of health conditions.

Certifications / Licenses: Valid License and Registration for Nursing Practice in PR.

Other: N/A

Languages: Spanish – Intermediate (comprehensive, writing and verbal)

English – Intermediate (comprehensive, writing and verbal)

“We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities.”