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Job Information

Sanford Health Medicare Programs Clinical Lead in Sioux Falls, South Dakota

Sanford Health is one of the largest and fastest-growing not-for-profit health systems in the United States. We're proud to offer many development and advancement opportunities to our nearly 50,000 members of the Sanford Family who are dedicated to the work of health and healing across our broad footprint.

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Facility: Cherapa Place Building
Location: Sioux Falls, SD
Address: 300 N Cherapa Pl, Sioux Falls, SD 57103, USA
Shift: 8 Hours - Day Shifts
Job Schedule: Full time
Weekly Hours: 40.00

Department Details

Sanford Health Plan is growing! We are seeking a candidate to support our Government Programs expansion efforts.

Job Summary

Leads clinical operations of Medicare programs with a primary focus in model of care delivery, healthcare effectiveness data and information set (HEDIS), Medicare star rating, risk adjustment and pharmacy. Works closely with the plan medical director, plan operations and provider groups to ensure the model of care is carried out to members consistently. Assumes the role as subject matter expert on the model of care and super trainer on the delivery of that model of care to plan providers and provider groups. Leads the quality improvement committee(s) established as a result of participation in Medicare programs. Completes gap assessment of healthcare effectiveness data and HEDIS measures and ensures providers are equipped to close remaining HEDIS gaps. Monitors star ratings and formulates action plans to achieve a four star or above rating. Interacts with pharmacy benefit manager (PBM) and pharmacists to streamline the delivery and increase the effectiveness of the plan's model of care.

Utilizes various resources to ensure providers are trained in the model of care. Consults with the care management team in an effort to create high-value clinical outcomes for members. Ensures Epic workflows, templates and documentation are created to fulfill all relevant HEDIS categories. Drives quality improvement initiatives to ensure HEDIS and chronic care improvement plan (CCIP) gaps are addressed and star ratings are optimized. Collaborates with plan providers to identify prescription alternatives for members based on quality, effectiveness and cost.

Monitors model of care metrics and takes action to achieve performance goals. Coaches providers and completes chart reviews to ensure completeness of documentation and appropriate model of care delivery based on members care needs, risk stratification and other relevant variables. Collaborates with IT to ensure that the collected HEDIS data is included in data files submitted to the payer and troubleshoots as necessary. Assists with the quality improvement review and audit related to potential quality risk issues and adverse events as part of any Medicare quality risk program. Completes chart reviews, documentation of findings, referral for medical director review and required reporting. Analyzes member risk score data and determines members that may not have all active diagnoses captured. Stratifies members and identify any hierarchical condition categories (HCC) that may be over/under reported and determine appropriate actions. Oversees the annual chart review process which includes validating the scope of medical record request list, completing oversight on any delegated vendors and ensuring providers are responding to requests.

Must be analytical and have critical thinking, problem solving and decision making skills. Must be organized and able to multi-task. Must be proficient in computer software such as Epic, Word and Excel.


Graduate from a nationally accredited nursing program preferred, including, but not limited to, Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), and National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA). Bachelor’s degree in nursing preferred.

Minimum of five years of nursing experience. Experience and knowledge of accreditation and regulatory agency standards preferred. Quality, medical coding, and/or risk adjustment experience is preferred.

Currently holds an unencumbered RN license with the State Board of Nursing where the practice of nursing is occurring and/or possess multistate licensure if in a Nurse Licensure Compact (NLC) state. Obtains and subsequently maintains required department specific competencies and certifications.


Sanford Health offers an attractive benefits package for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 401(k) retirement plan, work/life balance benefits, sick leave and paid time off. To review your benefit eligibility, visit .

Sanford is an EEO/AA Employer M/F/Disability/Vet. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-877-673-0854 or send an email to .

Sanford Health has a Drug Free Workplace Policy. An accepted offer will require a drug screen and pre-employment background screening as a condition of employment.

Job Function: Health Plan
Req Number: R-46969
Featured: No