Quality Care Improvement Specialist

• Build and maintain strong relationships with provider offices and clinic leadership.
• Conduct onsite and virtual provider outreach visits to review quality performance metrics, identify improvement opportunities, and retrieve relevant care gap closure data/records.
• Collaborate with assigned provider offices and health plans to improve documentation, coding accuracy, and care gap closure.
• Collect, review, and validate medical records to ensure accuracy and completeness for reporting purposes.
• Educate providers and office staff on quality measures, documentation standards, coding requirements, and best practices.
• Support monthly supplemental data submission, file preparation, and verification of compliant coding.
• Work with internal teams and vendors to validate, reconcile, and audit HEDIS records to ensure completeness and accuracy.
• Assist in developing QI initiatives such as outreach campaigns, provider education, and workflow optimization.
• Assist practices with workflow optimization, patient outreach strategies, and quality improvement interventions.
• Serve as a quality performance resource to assigned health plan partners, provider groups, clinics, and MSOs, providing and presenting HEDIS performance scorecards monthly.
• Monitor HEDIS progress dashboards and address data gaps prior to final submission.
• Prepare reports, scorecards, and presentations for leadership review.
• Obtain data needed for Primary Source Verification audits from health plans and vendors and ensure timely submission.
• Act as a subject matter expert on CMS, HEDIS, NCQA, HIPAA, and health plan standards.
• Conduct comprehensive training for PCPs and specialists on Quality Measures, HEDIS and CMS Star Ratings, Performance-Based Incentive Programs, Data Accuracy and Documentation Standards.
• Perform additional duties and projects assigned.
• Perform additional duties and projects assigned.

• Bachelor’s degree or equivalent experience
• 3–5 years of experience in healthcare, ideally in IPA/MSO/Health Plan environments
• Minimum of 1 year of HEDIS-related experience
• Independent transportation and ability to travel up to 25% as needed
• Strong knowledge of managed care and quality program standards
• Excellent analytical, communication, and presentation skills
• Demonstrates initiative, creativity, and a collaborative mindset
• Fluent in Spanish and/or Chinese (Mandarin/Cantonese)

Demonstrates expertise in HEDIS, quality improvement initiatives, and healthcare documentation standards while effectively collaborating with provider offices and health plans to enhance care quality and compliance. Proficient in data analysis, reporting, and training on quality measures and coding requirements.

• HEDIS Experience
• Quality Improvement Initiatives
• Healthcare Documentation Standards
• Data Analysis and Reporting
• Fluent in Spanish and/or Chinese

• Quality Performance Metrics
• Coding Accuracy
• Care Gap Closure
• Medical Record Validation
• Data Submission and Verification
• HEDIS Record Auditing
• Performance-Based Incentive Programs
• Primary Source Verification
• Quality Measures Education
• Managed Care Standards

• Analytical Skills
• Communication Skills
• Presentation Skills
• Initiative
• Collaborative Mindset

• CMS Standards
• NCQA Standards
• HIPAA Compliance
• IPA/MSO/Health Plan Environments

• HEDIS Dashboards
• Scorecards
• Reporting Tools
• Data Management Systems