The responsibilities of this position demand, team player as well as a wide range of capabilities including: strategic planning and analysis skills; strong understanding of HEDIS and coding; management breadth to direct and motivate; highly developed communication skills; and the ability to develop clear action plans and drive process, given often ambiguous issues with numerous interdependencies. This position will facilitate any unresolved issues that remain as a result from following the standard process.
Collaboration between HEDIS Manager, Quality Director and Chief Medical Officer on improved innovation and process improvement. Work with the Quality Improvement team to collect member charts for review. Provide over site of abstracted records, quality assurance and data entry.
Facilitate communication between providers and health plan to optimize health and wellness, reduce inpatient admission, reduce re-admissions and improve medical stability in the patient population served. Responsible for the coordination of HEDIS data, gathering processes by evaluating quality and completeness of clinical documentation processes. Performs quality medical record reviews, assisting providers and staff in the improvement of clinical documentation, identifying trends and gaps in care, maintaining accurate records of review activities, ensures all data submitted to the health plan meets HEDIS technical specifications for medical records. Participates in the development and ongoing implementation of quality improvement activities by providing regular and ongoing provider/staff support and education.
- Manage care gaps in collaboration with the quality team, and provider offices.
- Request records from provider's offices as needed and perform a review of medical records for data collection, data entry, and quality monitoring, which allows health plan to review accuracy of documentation, and a possibility to close gaps in care.
- Responsible for over reading abstracted HEDIS measures, during the HEDIS season.
- Observe and Identify trends and potential strategies by collaborating with the HEDIS Manager, and health plan staff.
- Track and trend barriers / challenges that exist to achieve better outcomes, including access to appointments, lack of follow up, or documentation.
- Communicate scheduling challenges or trends that may negatively affect quality outcomes.
- Activities will include data collection, data entry, quality monitoring, health plan and chart collection activities.
- Navigate multiple EMR systems and obtain medical record sections supportive of HEDIS measures.
- Maintains education / knowledge base of HEDIS / STARs.
- Performs all other related duties as assigned.
- Work collaboratively with others via workgroups.
- Bachelor's or Associates degree - Registered Nurseor Vocational/technical school graduate- Licensed Vocational Nurse.
- Knowledge of lab procedures and diagnostic testing.
- Ability to write clear documentation and ability to write detailed specifications.
- Solid organizational skills including attention to detail and multi-tasking skills.
- Basic computer skills.
- EMR Experience.
- 4 years clinical experience preferred.
- HEDIS Experience required, 2 or more years. 3+ is preferred.
- Experience working in a provider and / or medical office.
- RN or LVN/LPN License in the state of TX or where positions is located within the enterprise.