This is a quality-focused, telephonic LVN position supporting HEDIS and Medicare STAR quality initiatives. The primary responsibility is identifying members who have open healthcare quality gaps and helping them take the appropriate steps to close those gaps. This is not a traditional bedside nursing position. The role combines high-volume member outreach, patient education, care coordination, HEDIS/STAR quality measures, documentation, and data review. What You'll Be Doing A significant part of the position involves making high-volume outbound calls to health plan members using an auto-dialer.
During these calls, you may:
- Contact members who have open HEDIS/STAR care gaps
- Discuss medication adherence and determine why a member may not be taking or refilling a medication
- Educate members on recommended screenings, appointments, or quality measures
- Help members schedule appointments or pharmacy consultations
- Identify barriers preventing members from completing recommended care
- Follow required call scripts and verify member information
- Accurately document every member interaction
- Occasionally handle inbound member calls and questions
- Contact providers or clinics to obtain missing information or documentation
Examples of Care Gaps
A member may appear as having an open quality gap because they:
- Are overdue for a preventive screening
- Have not completed a recommended diabetes-related test or exam
- Have not refilled a medication as expected
- Need a follow-up appointment
- Completed the service, but the health plan is missing the documentation
The goal is to determine why the gap exists and what can be done to close it.
HEDIS & STAR Responsibilities In addition to member outreach, the LVN will review quality data and help monitor HEDIS/STAR performance. Responsibilities may include reviewing data for missing or inaccurate information, identifying trends and barriers, monitoring quality performance, and working with PCPs/clinics to improve quality outcomes.
CAHPS & HOS
The position may also involve educating members on topics related to:
CAHPS (Consumer Assessment of Healthcare Providers and Systems): Focuses primarily on the member's experience with their healthcare and health plan, including access to care, communication, and customer service. HOS (Health Outcomes Survey): Focuses on members' health and functional status and health-related topics such as physical activity and fall risk.
What They're Looking For
Candidates should have:
- Active LVN/LPN license
- Healthcare experience, ideally within managed care
- Previous HEDIS/STAR or healthcare quality experience
- Experience reviewing healthcare data and/or medical records
- Strong patient/member communication skills
- Comfort making high-volume outbound calls
- Strong documentation and attention-to-detail skills
- Ability to navigate multiple computer systems while speaking with members
- Microsoft Office experience, particularly Excel