Clinical STARS-HEDIS Audit Specialist

3 weeks ago

Philadelphia, United States Jefferson Health Plans Full time

Why Choose Jefferson Health Plans?


We are an award-winning, not-for-profit health maintenance organization offering Medicaid, Medicare, and Children’s Health Insurance Program (CHIP) plans that include special benefits to improve the health and wellness of our members. We are committed to creating a community where everyone belongs, acknowledges, and celebrates diversity and has opportunities to grow to their fullest potential.


While this job currently provides a flexible remote option, due to in-office meetings, training as required, or other business needs, our employees are to be residents of PA or the nearby states of DE or NJ.


Perks of JHP and why you will love it here:

  • Competitive Compensation Packages, including 401(k) Savings Plan with Company Match and Profit Sharing
  • Flextime and Work-at-Home Options
  • Benefits & Wellness Program including generous Time Off
  • Impact on the communities we service


We are seeking a talented and enthusiastic Clinical STARS-HEDIS Specialist to join our team


The Clinical STARS-HEDIS Specialist will provide clinical support to the Quality Management department as well as other areas throughout the organization in order to assist with Care Gap Closure. The Specialist will contribute to quality initiatives and activities, conducting provider outreach calls, and medical record reviews to help drive HPP’s performance as it relates to Stars, HEDIS, NCQA Accreditation, CAHPS, and Patient-Centered Medical Home (PCMH).


As the Clinical STARS-HEDIS Specialist, your daily duties may include:

  • Conduct provider outreach calls to complete clinical/quality assessments related to HEDIS and Stars, including pain and functional assessments
  • Conduct quality medical record reviews to ensure a continuum of care management effectiveness and to report to the PCP potential gaps and adherence issues against clinical, HEDIS, Stars, Credentialing and Re-credentialing, and other regulatory objectives
  • Assist the Quality Management team by conducting medical chart reviews or overreads during the HEDIS season
  • Identify quality-related issues and recommend potential solutions
  • Identify and share best practices, a significant contribution to process improvement initiatives, and actively support these initiatives
  • Collaborate with internal departments (such as HEDIS, Care Management, UM, enrollment, member services, and Complaints and Grievances) to facilitate resolutions for potential quality issues and concerns
  • Document appropriately in the Care Management system, Access, Excel files, and other areas, as needed, by departmental requirements
  • Operate CIC and telephone systems effectively and efficiently, following established protocols for security, transfer, and information exchange
  • Other duties as assigned


Qualifications

  • Bachelor’s Degree in Nursing preferred, but not required
  • Current PA Healthcare License to practice required
  • 3-5 years’ experience in managed care, clinical case management or quality review required


Skills, We Value:

  • Proficient use of Microsoft Office, SharePoint and Teams required
  • Experience with various electronic medical records (EMRs) preferred
  • Knowledge of clinical case management, medical terminology required
  • Ability to read and interpret standards to perform certain functions of the job required
  • Exceptional presentation, oral and written communication, interpersonal, problem solving, multitasking and time management skills required
  • Exceptional customer service skills required
  • Ability to organize and manage multiple priorities
  • Ability to work independently and as part of a team required
  • Valid driver’s license and insurance. Ability to travel (to and from office sites), as needed. Moderate walking required. Lift/push/pull/hold/carry up to 10 pounds.

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