To be fully engaged in providing Uncompromised Safety, Superior Quality, Memorable Member/Customer Experiences, and Financial Stewardship by working closely with other departments to assure regulatory compliance and the overall success of the Quality Management (QM) Programs for Health First Health Plans, Inc. The Quality Improvement Coordinator will assist in coordination of data collection of HEDIS and state-mandated quality metrics specification, abstraction, auditing and review as well as identifying processes that enhance improvement in quality programs and the care of HFHP membership. The Coordinator is responsible for provider, office staff and intradepartmental collaboration including staff education and interventions relative to clinical quality initiatives as well as key quality and performance indicators.
This position is responsible for ongoing data collection and Performance improvement activities at the Health plan and reports to the Manager of Clinical Effectiveness.
Coordinates and performs onsite medical record reviews at targeted provider offices to determine the appropriate documentation, coding and billing practices, assisting with workflow analysis to enhance compliance with quality metrics, service delivery and quality standards.
Maintains current knowledge of HEDIS and state-mandated quality metrics specifications, and proficiency with the vendor’s reporting software to provide analytic support with data quality review, care gap analysis and reports.
Educates department staff, providers and office staff on applicable coding and billing practices, HEDIS and state-mandated quality metrics specifications, provider profiling for performance measurement, and medical record review criteria.
Prepares confidential Member-specific service summary files of claims/encounter data history for review for approved outside entity (regulatory agencies). Maintains data integrity.
Supports quality improvement programs and studies by requesting records from providers, maintaining databases, and researching health plan encounter data on an ongoing basis.
Assists with implementing audits, surveys, and with tracking, trending and analysis of data for clinical and non-clinical QM activities.
Participates in and represents the health plan at community and other organizational meetings focusing on quality improvement, member education, care gap completion, risk reduction and other areas as assigned.
Performs continuing medical record evaluation, follow-up education, and practitioner intervention as required.
Ability to present information and insight to quality improvement initiatives to committee and work group environments.
Participates in QM readiness for regulatory agency audits, accreditation surveys, respond to RFPs and with preparation of reports and documents
Other duties as assigned.
Communicates with physicians and providers concerning quality and HEDIS Initiatives, Performance Improvement Programs, providing timely quality improvement opportunities using provider care gap reports.
Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand
Current, unrestricted RN license preferred, other clinical experience or other relevant quality improvement experience, HEDIS, Health Plan experience may be considered.
Bachelor’s degree or related science preferred
Two or more years in Managed Care setting or Quality Management experience preferred.
Must have proficiency in health care related applications, EMR, Word, Excel, and a basic understanding of database management.
Must be able to abstract data, and present data in clear reporting formats to support comparison and analysis.
Knowledge base of clinical standards of care, preventive health standards, HEDIS, NCQA, governing and regulatory agency requirements, and the managed care industry.
Must have solid mathematical skills, and demonstrate accuracy in tabulation of data and calculation of rates based on defined numerators/denominators.
Must have analytical skills sufficient to assess and identify variations in data and processes.
Ability to travel to physician offices; valid state-specific driver's license and reliable vehicle.
Ability to evaluate medical records and data with attention to detail
Ability to interact with medical staff, peers, and internal company staff at all levels.