Quality Practice Advisor

» Quality Practice Advisor
Information Technology
in Las Vegas
, NV
Reference: 19-03389

Key Duties and Responsibilities:

  • Advises and educates large Provider practices and IPAs in appropriate HEDIS measures, medical record documentation guidelines and HEDIS ICD-9/10 CPT coding in accordance with NCQA requirements
  • Collects, summarizes and trends provider performance data to identify and strategize opportunities for provider improvement
  • Collaborates with Provider Relations to improve provider performance in areas of Quality, Risk Adjustment and Operations (claims and encounters)
  • Delivers provider specific metrics and coach providers on gap closing opportunities
  • Identifies specific practice needs where the client can provide support
  • Develops, enhances and maintains provider clinical relationship across product lines
  • Defines gaps in the client’s service relationship with providers and facilitate resolution
  • Leads and/or supports collaborative business partnerships, elicit client understanding and insight to advise and make recommendations
  • Partners with physicians/physician staff to find ways to explore new ways to encourage member clinical participation in wellness and education
  • Provides resources and educational opportunities to provider and staff
  • Captures concerns and issues in action plans as agreed upon by provider
  • Documents action plans and details of visits and outcomes and reports critical incidents and information regarding quality of care issues
  • Communicates with external data sources as needed to gather data necessary to measure identified outcomes
  • Provides communication such as newsletter articles, member education, outreach interventions and provider education
  • Supports quality improvement HEDIS and program studies as needed, requesting records from providers, maintaining databases, and researching to identify members’ provider encounter history
  • Ensures that documentation produced and/or processed complies with state regulations and/or accrediting body requirements
  • Ensures assigned contract/regulatory report content is accurate and that submission adheres to deadline
  • Participates in and represents plan at community, health department, collaborative and other organizational meetings focusing on quality improvement, member education, and disparity programs, as assigned
  • Ensures accuracy in medical records for data collection, data entry and reporting
  • Enters documentation of findings in identified databases
  • Performs other duties as assigned

Education:

  • A Bachelor’s Degree in Healthcare, Public Health, Nursing, Psychology, Health Administration, Social Work or related field Required
  • Equivalent work experience of 3 + years directly related HEDIS record collection with analytical review/evaluation and/or Quality Improvement
  • A Master’s Degree in Healthcare, Public Health, Nursing, Psychology, Health Administration, Social Work or related field Preferred

Work Experience:

  • 2+ years of experience in directly related HEDIS medical record review and/or Quality Improvement with experience in data and chart reviews to provide consultation and education to providers and provider staff Required
  • 1+ year of experience in Managed Care experience Required

Licenses and Certifications:

  • One of the following is required:
    • Certified Coding Specialist
    • Licensed Practical Nurse
    • Licensed Clinical Social Worker
    • Licensed Mental Health Counselor
    • Licensed Master Social Work
    • Licensed Marital and Family Therapist
    • Licensed Vocational Nurse
    • Licensed Registered Nurse
    • Acute Care Nurse Practitioner
    • Health Care Quality and Management
    • Certified Healthcare Professional
    • Certified Professional in Healthcare Quality

Skills:

  • Demonstrated interpersonal/verbal communication skills
  • Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
  • Ability to multi-task
  • Ability to work in a fast paced environment with changing priorities
  • Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
  • Ability to implement process improvements
  • Ability to effectively present information and respond to questions from families, members, and providers
  • Ability to influence internal and external constituents
  • Demonstrated analytical skills
  • Demonstrated customer service skills
  • Ability to analyze information and covert related activities into a comprehensive work plan
  • Demonstrated organizational skills
  • Knowledge of healthcare delivery
  • Other Understanding of data analysis and continuous quality improvement process

Technology:

  • Microsoft Excel
  • Microsoft Word
  • Microsoft Outlook
  • Healthcare Management Systems (Generic)
  • Microsoft PowerPoint