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LE0002 MMM Holdings, LLC

It's fun to work in a company where people truly BELIEVE in what they're doing!

We're committed to bringing passion and customer focus to the business.

POSITION DESCRIPTION

The Quality Specialist Nurse is responsible for monitoring quality of care and services delivered to Members including provider site visits and medical record reviews.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Collaborates in the implementation of educational activities geared at improving quality measures. Coordinates quality assessment activities related to clinical areas in conjunction with the Quality Director in all service areas. Performs provider site visits in all MMMHC/PMC service areas and medical record reviews in accordance with the policies and procedures. Performs medical record review in physician’s offices of selected HEDIS sample. Performs follow audit to those providers with a score below 80% in either medical record documentation or physician office standards. Documents findings of audits into the Physician Audit application electronic system. Performs onsite visits to providers for investigation of quality of care issues and documents findings in the forms develop for that purpose. Prepares letters of findings to be sent to provider and discuss with Medical Director for signature. Maintains a log of visits and findings by provider. Performs activities in compliance with MMM Healthcare/PMC and CMS requirements. Prepares and submits to the Quality Director a monthly report of activities performed. Performs other duties relevant to the position.

EDUCATION AND EXPERIENCE

Bachelor’s Degree of Science of Nursing from an accredited school of nursing. Current unrestricted Generalist Nursing license to practice in Puerto Rico. Minimum of three years of experience in clinical nursing. Previous QA review experience preferred.

GENERAL SKILLS AND KNOWLEDGE

• Must have ability to work as a team player with excellent communication skills.

• Must solve resource issue in a creative, positive manner.

• Must possess the ability to make independent decisions when circumstances warrant such action.

• Must have knowledge of local community resources

• Computer literate in Microsoft Windows applications, software and Internet

LANGUAGE SKILLS

Ability to speak, read and write in English and Spanish, preferable Bilingual in English to Spanish. Ability to read, analyze, and interpret general business periodicals, operating and maintenance instructions, procedure manuals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.

MATHEMATICAL SKILLS

Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

REASONING ABILITY

Define problems, collect data, establish facts, and draw valid conclusions. Interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables

INTERPERSONAL RELATIONS

Internal Contacts

• Staff employees

• Management at all levels of the organization

External Contacts

• External Providers

• External Clients

• Vendors

• Government and Federal Agencies

PHYSICAL AND MENTAL DEMANDS

Requires sitting and standing associated with a normal office environment; mobility to complete hospital rounds and other errands. Regularly talks and hears. This position requires that weight be lifted or force be exerted up to 10 pounds.

ENVIRONMENTAL AND WORKING CONDITIONS

Normal busy office environment (examples: business office with computers and printers, light traffic). The noise is typically moderate. Travel around different locations required. General exposure to weather conditions while traveling. Valid driver’s license required. A flexible schedule which could involve evening, holiday and weekend work.

If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!

Innovacare, Inc. is the leading provider of healthcare management in North America. Through two it’s main ways, Medicare Advantage and the provider network, we are committed to healthcare, creating models that are sustainable, cost-effective, and fully integrated with the most advanced technologies. Innovacare, Inc. combines innovation and quality care to create progressive, value-based models, even for the neediest patient populations. Our leadership team, with its vast years of combined experience in managed care and care delivery, is made up of leading experts with proven experience to help healthcare organizations effectively meet and exceed the growing demands of our industry.

InnovaCare Health's foundation was laid by President and CEO Richard Shinto, M.D., in 1998, when he joined North American Medical Management (NAMM) in California. Over the next 10 years, the company continued to grow, acquiring MMM Healthcare in Puerto Rico. In December 2012, the management team successfully sold select NAMM properties and officially formed InnovaCare Health to operate the remaining subsidiaries, including MMM. MMM Holdings, is a conglomerate of companies that work on Puerto Rico's business strategies, both for Medicare Advantage beneficiaries, through Medicare y Mucho Más (MMM), and for the beneficiaries of the government health plan with MMM Multihealth. Through InHealth Management, it manages the in-hospital care of the beneficiaries, while the specialized clinics, MMM Vita Care, serve members with chronic conditions. On the other hand, MSO of Puerto Rico supports medical groups, providers and other entities in the health industry, while Castellana Physicians Services is a medical group dedicated exclusively to providing services for the elderly and disabled population in Puerto Rico.

At the same time, the main company manages Medicare and Much More, a Medicare Advantage population health plan with a presence in Miami-Dade, Broward and Palm Beach counties. With a Mobile Application that allows members to check the status of their pre-authorizations, access their provider directory and schedule their future medical visits, Medicare and Much More integrates technology as a tool to improve the member experience. Also, the plan will ensure the health of members, during and after natural disasters. Through the Florida MMM Line of Care, as a Part D sponsor, you will ensure that the member has adequate access to their covered Part D drugs.

Orlando Family Physicians, a group of clinics that provide comprehensive care services in the state of Florida, is another of the companies managed by Innovacare, Inc. With more than 20 years of service in the Central Florida community and more than 100,000 patients cared, Orlando Family Physicians offers the personalized treatment and care that the patient deserves. With a track record that proves excellent customer service, we are proud that the largest Hispanic medical group in Central Florida has joined us. Our constant growth is the best witness we have to tell that things are being done well, so it is our commitment to continue on this path.

Innovacare, Inc. es el proveedor líder de manejo de servicios de salud en Norteamérica. A través de dos principales vías, Medicare Advantage y la red de proveedores, estamos comprometidos al cuidado de la salud, creando modelos que son sostenibles, costo-efectivos y completamente integrado a las tecnologías más avanzadas. Innovacare, Inc. combina innovación y atención de calidad para crear modelos progresivos y basados en el valor, incluso para las poblaciones de pacientes de mayor necesidad. Nuestro equipo de liderazgo con sus vastos años de experiencia combinada, en atención administrada y prestación de atención, está formado por expertos preeminentes con la experiencia comprobada para ayudar a las organizaciones de atención médica a satisfacer y superar eficazmente las crecientes demandas de nuestra industria.

Las bases de InnovaCare Health fueron establecidas por el presidente y CEO Richard Shinto, M.D., en 1998, cuando se unió a North American Medical Management (NAMM) en California. Durante los próximos 10 años, la compañía continuó creciendo, adquiriendo MMM Healthcare en Puerto Rico. En diciembre de 2012, el equipo de gestión vendió con éxito propiedades selectas de NAMM y formó oficialmente InnovaCare Health para operar las filiales restantes, incluida MMM.

MMM Holdings, es un conglomerado de compañías que trabaja las estrategias de negocio de Puerto Rico, tanto para Medicare Advantage, a través de Medicare y Mucho Más (MMM), como para los beneficiarios del plan de salud del Gobierno con MMM Multihealth. A través de InHealth Management maneja el cuidado intrahospitalario de los beneficiarios, mientras que, las clínicas especializadas, MMM Vita Care, atienden afiliados con condiciones crónicas. Por otro lado, MSO of Puerto Rico apoya grupos médicos, proveedores y otras entidades en la industria de la salud, mientras Castellana Physicians Services es un grupo médico dedicado exclusivamente a proveer servicios para la población de edad avanzada y discapacitada en Puerto Rico.

A su vez, la compañía matriz maneja Medicare and Much More, plan de salud para la población Medicare Advantage con presencia en los condados de Miami-Dade, Broward y Palm Beach. Con una Aplicación Móvil que permite a los afiliados verificar estatus de sus pre-autorizaciones, acceder su directorio de proveedores y agendar sus futuras visitas médicas, Medicare and Much More integra la tecnología como una herramienta para mejorar la experiencia del afiliado. También, el plan velará por la salud de los afiliados durante y después de desastres naturales. Por eso, a través de la línea de cuidado MMM de Florida, como patrocinador de la Parte D, se asegurará de que el afiliado tenga acceso adecuado a sus medicamentos cubiertos de la Parte D.

Orlando Family Physicians, grupo de clínicas que brindan servicios para el cuidado integral en el estado de la Florida, es otra de las compañías manejadas por Innovacare, Inc. Con más de 20 años de servicio en la comunidad de Florida Central y más de 100.000 pacientes atendidos, Orlando Family Physicians ofrece el tratamiento personalizado y la atención que el paciente merece. Con una trayectoria que prueba un excelente servicio al cliente, estamos orgullosos de que el grupo médico hispano más grande en Florida Central se haya unido a nosotros. Nuestro constante crecimiento es el mejor testigo de que las cosas se están haciendo bien por lo que es nuestro compromiso continuar por ese camino.