Government Programs Clinical Quality & HEDIS Specialist

Job Summary This position will have split responsibility between HEDIS abstraction and quality work and member/provider engagement to improve overall quality performance. The individual will be responsible for conducting telephonic care coordination for members by identifying opportunities for intervention, including preventative care screenings, disease state management, appropriate medication use, and other key health care needs. This position will access appropriate health-related services and work closely with members, pharmacies, and physicians to help ensure that members have comprehensive and coordinated care to improve clinical government program quality and performance.

The specialist will also be responsible for extensive knowledge of HEDIS measures to facilitate abstraction of medical records to allow for gap closure and additional data gathering.

RequirementsEDUCATIONBachelor’s degree in Health Science, Public Health, Psychology, Social Work, Health Administration, or other healthcare related field. In lieu of degree, five (5) years' related experience will be considered. Likewise, an associate degree in one of the above fields can be used in conjunction with an additional two (2) years' related experience to meet the Education requirement.

LICENSING/CERTIFICATION Valid Driver’s License Must successfully pass the Inter-Rater Reliability (IRR) test within 90 days of hire and/or assignment into the position.

An active licensure or certification in one of the following is preferred:
Registered Nurse (RN), Licensed Practical Nurse (LPN), Licensed Baccalaureate Social Worker (LBSW), Certified Pharmacy Technician (CPht).Certified Professional Coder (CPC) preferred, but not required.

EXPERIENCE Minimum three (3) years' work experience in one of the following:

Direct patient care, social work, quality improvement or health coaching, preferably in a managed care environment OR Clinical, healthcare service quality improvement, or health data analytics, preferably involving Stars/HEDIS and/or medical record review audit.

Minimum one (1) year of experience in Medicare Advantage required.

Experience working directly with patients required.

Knowledge of and ability to work within a complex health care system including advocating for member needs while balancing organization needs.

Understand needs of culturally diverse populations including ability to evaluate for literacy and literacy needs.

Experience as a health navigator, patient navigator, patient advocate, care advocate, or health coach strongly preferred.

Experience working closely with and/or advocating for individuals who are culturally diverse and/or in positions of lower socioeconomic status preferred.

ESSENTIAL SKILLS & ABILITIES Must achieve passing score of 95% to align with auditor requirements for passing of IRR test. If, following training and re-test, the employee fails to pass after a second attempt, the employee will be subject to disciplinary action per the terms of the Performance Standards Manual requirements.

Excellent written and verbal communication skills interacting with individuals internally and externally.

Strong independent, critical thinking skills to understand individual and operational problems and identifying appropriate solution(s).Strong interpersonal, presentation, problem-solving and organizational skills.

Proficiency in Microsoft Office Applications (Word, Excel, PowerPoint, Outlook).Ability to travel, as necessary, within the designated service area required.

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

Ability to work independently in Microsoft Office applications with little to no training required.

Ability to…