Government Programs Clinical Quality, HEDIS Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Facilitate telephonic care coordination and health coaching for members and their families

• Recognize opportunities for preventive care, disease management, medication adherence, and other healthcare interventions

• Access suitable health-related services and coordinate care with members, pharmacies, physicians, and providers

• Retrieve, abstract, and review clinical medical records for HEDIS audit activities and quality-gap initiatives

• Ensure accuracy in medical record reviews and compliance with CMS quality initiative guidelines

• Develop work and progress plans for members based on interactions and insights

• Assist members in scheduling appointments and navigating the healthcare delivery system

• Identify and triage members to the appropriate healthcare resources while resolving barriers to care

• Measure, analyze, and report on HEDIS quality initiative results

• Create tools to capture and report information regarding member and provider quality-gap trends

• Develop educational materials for members and practitioners

• Support quality improvement initiatives

• Build relationships and act as a liaison and advocate among members, providers, health departments, and community organizations

• Conduct provider outreach, including distributing gap reports and retrieving medical records

• Monitor gap closures and improvement activities in collaboration with Stars Member Outreach Specialists, Stars Improvement Nurses, and health plan staff

• Execute additional activities and projects as directed by Clinical Quality & HEDIS leadership

⛳️ Requirements

• Bachelor’s degree in Health Science, Public Health, Psychology, Social Work, Health Administration, or another healthcare-related field; five years of relevant experience may substitute for the degree

• An associate degree in a listed field along with two additional years of relevant experience may fulfill the education requirement

• At least three years of work experience in direct patient care, social work, quality improvement, health coaching, clinical or healthcare service quality improvement, or health data analytics

• Minimum of one year of experience in Medicare Advantage

• Experience interacting directly with patients

• Valid driver’s license required

• Must successfully pass the Inter-Rater Reliability (IRR) test within 90 days of hire and/or assignment

• Must achieve a passing score of 95% on the IRR test

• Knowledge of complex healthcare systems and the ability to advocate for member needs

• Understanding of culturally diverse populations and the ability to assess literacy needs

• Proficiency in Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook

• Ability to travel within the designated service area as required

• Ability to protect confidential healthcare information and comply with applicable laws, policies, rules, and regulations

• Skill in assessing needs and designing, developing, and implementing goal-oriented care plans

• Ability to identify issues, gather data, establish facts, and draw valid conclusions

• Active RN, LPN, LBSW, or CPht licensure/certification preferred

• CPC certification preferred but not mandatory

• Experience as a health navigator, patient navigator, patient advocate, care advocate, or health coach is highly preferred

• Strong understanding of HEDIS measures and technical specifications preferred

• Experience in medical record abstraction, claims coding, education, and training is preferred

• Bilingual ability is a plus

🏝️ Benefits

• Regular employment opportunities

• Remote work arrangement available

• Campus travel within walking distance of the primary work location

• Opportunities for professional development and training related to HEDIS abstraction, quality improvement, and care coordination