Clinical Quality Specialist
3 days ago
We are seeking a highly skilled Registered Nurse to join our team as a Clinical Quality Specialist. In this role, you will play a critical part in improving the quality of care for our members.
Key Responsibilities- Telephonic and follow-up with members to close care gaps
- Provider outreach to address care gaps
- Chart upload in Practice Assist to close care gaps
- Support HEDIS chart chase efforts by reaching out to providers to retrieve medical records
- Support STARS improvement projects, HEDIS, CAHPS measures and provide clinical guidance
- Support Health Plans as Subject Matter Expert of STARS and HEDIS Technical Specifications, project plans, and reporting logistics
- Identify and implement opportunities to improve rates or efficiency of data collection
- Support National Team efforts
- Educate providers on general policies and procedures applicable to delivery of care
- Educate providers on proper HEDIS documentation/coding for member compliance
- Engage providers to introduce new initiatives and monitor success of those in place and to identify issues and ensure effective problem resolution to maintain strong relationships
- Serves as the primary point of contact, consultative resource, and subject matter expert in all aspects of medical record documentation requirements and coding as they apply to CMS Stars/HEDIS measures
- Closely work with internal stakeholders and providers to engage members and close care gaps
- Weekly and monthly productivity reports for outreach (Corral, Provider Letter campaign, Compassion Cards)
- Ensure projects are completed on time and in scope
- Support the evaluation and monitoring of HEDIS/Stars specific QM Metrics
- Monitor of reports and playbook
- Need to work independently and within an integrated team in a highly matrixed environment
- Attend weekly/monthly and adhoc Webex meetings with national partners (National Star Operations Meetings, Stars Measure Meetings, and Various measure groups, etc.)
- Travel locally in Arizona (25%) to meet with provider groups and healthcare quality or policy organizations
- Registered Nurse with no restrictions in state required to practice
- 3+ years of experience working in a healthcare environment
- 3+ years of experience of project management
- 3+ years of experience in tracking, working with large data sets and making data-driven analytical decisions
- 2+ years of Medicare, DSNP Lines of business
- 2+ years of Stars, HEDIS measure technical specifications
- Experience reaching out to member to close care gaps
- Intermediate or higher level of proficiency with Excel and PowerPoint, including visual representation of quality data and trends, use of basic math and statistics functions
- Access to reliable transportation with valid driver's license that will enable you to travel to client and/or sites within designated area
- Candidate must be based in Arizona (Phoenix, Tucson, or Mesa)
- UnitedHealth Group, Optum, or UnitedHealthcare experience
- Community & State and or Medicare & Retirement experience
- Demonstrated ability to communicate ideas clearly and concisely
- Flexibility and quick adaptation to change is key
- Continuous improvement mindset
- Excellent time management, organizational, and prioritization skills and ability to balance multiple priorities
We are an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
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