HEDIS Specialist

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Full Time Miami, FL, US

Borinquen Medical Centers is based in Miami, Florida and is seeking to hire a full-time HEDIS Specialist to join our team. This position is responsible for communicating provider participation information to stated internal and external customers through established processes to allow for appropriate patient scheduling and reimbursement for services rendered to meet and exceed HEDIS & P4P measures. Responsible for verifying and updating patient registration information, including insurance, demographic and patient data.

Work collaboratively with all Departments to resolve registration issues. Support QI, Policy & Procedures and the Care team. This member of the Care team will be in charge to ensure patients comply with disease management goals (Pre and post call documentation), documenting in the E.H.R. to ensure continuity of care. The quality care person will provide reports on these activities on a daily, weekly and monthly basis to the QI Manager dependent on the E.H.R. data entered and HEDIS.

This position is also responsible for t racking patient number of visits attending BMC and ensuring access to care by minimally following standard care guidelines.

• Coordinating and completing HEDIS quality specific projects ensuring consistency with BMC strategy, commitments, and goals.
• Obtain patient roster from participating health insurance plans.
• Call Patients that are Registered to set an appointment;
  Evaluate Quality Management Tab, Avhana & HEDIS.
• Validate roster;
  Schedule appointments and ensure compliance with quality measures.
• Track Quality measures and sell BHCC services if needed and determine reason for appointment.
• Assist with Chronic Care management (CCM) Share medical Appointments;
  Complete Care Gaps;
  Assist with group visit.
• Track hospitalization discharges and bring the patients for continuity of care.
• Proactively seek resources to identify gaps on existing or quality projects as they arise.
• Performs other analyses to assist with documentation.
• Periodically audit records to confirm compliance with HEDIS and NCQA standards.
• Ensures that all scheduled and tracking attended patients fulfill their care gaps and documents barriers of patients to do so.
• Responsible for verifying and updating patient registration information, including insurance, demographic and patient data when scheduling appointment.
• Maintains internal rosters to mitigate inadvertent leakage resulting from incorrect listings.
• The ability to retrieve, communicate, present data and information both verbally and written.
• Provides paneling information provided to Health Plans is accurate and timely.
• Coordinates with Quality Manager on a weekly basis.
• Chart Audit:
  Internal and External Chart Audits when requested.
• Perform and track call campaigns for non- compliant patients to increase access to care.
• Increase and track access to care for patients that have not attended in the last six months their primary care provider visit.
• Provides patients with covered benefits and services that their primary health plan offers.

• Well organized and Bilingual (Spanish and/or Creole).
• Computer literacy with proficiency and expertise in Microsoft Office, including Outlook, Word, and Excel.
• Ability to interact effectively with patients, administration, faculty, and staff.
• Handle information with high level of confidentiality.
• Considerable knowledge of standard concepts, practices, and procedures within a field.
• Relies on limited experience and judgment to make decision, plan and accomplish goals.
• Minimum 1 year of customer service.
• Strong interpersonal skills.
• Bachelor’s Degree.
• Experience in clinical background setting (LPN, MA) with case management experience.

• Medical/Dental/Vision/Short Term Disability