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