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Quality Assurance Coordinator I

2 months ago

Rochester, New York, United States Excellus Health Plan Inc. Full time

Job Overview:

Position Summary:

This role is dedicated to overseeing quality assurance initiatives, which encompass HEDIS/QARR/QRS processes, addressing quality of care issues, adhering to NCQA standards, and conducting medical record evaluations and studies mandated by the Health Plan to comply with regulatory obligations.

Furthermore, the quality division aligns with the objectives and strategies of the Risk Adjustment Department.

Key Responsibilities:
Level I
Assists in fulfilling extensive reporting obligations for required reporting, including HEDIS/QARR/QRS.
Records all procedures and protocols associated with the current HEDIS hybrid review strategy.
Designs, executes, and supervises the hybrid audit framework to satisfy external audit standards.

Utilizes healthcare expertise to evaluate the completeness and reliability of data and the validity and accuracy of outcomes for hybrid metrics.

Conducts thorough reviews, analyses, and completes all required studies and medical record assessments as mandated by CMS, NYS DOH, or other regulatory bodies.
Collaborates effectively with both internal and external stakeholders to promote Health Care Improvement while providing education on metrics and performance.
Executes detailed medical record documentation assessments for providers and reports findings to credentialing and relevant internal committees.
Monitors and assesses data from hybrid review outcomes for reporting purposes. Presents program activities and performance internally.
Supports and drives initiatives to achieve the Risk Adjustment & HEDIS Strategic Goals and Objectives.
Embraces and leads change while consistently exhibiting a positive and proactive attitude.

Maintains and updates the quality of care concerns process in collaboration with Medical Directors and, if necessary, the NYS Department of Health (DOH).

Consistently upholds high standards of integrity by endorsing the mission and values of Lifetime Healthcare Companies, adhering to the Corporate Code of Conduct, and embodying the Lifetime Way values and beliefs.

Ensures member privacy is respected in accordance with corporate privacy policies and procedures.
Regular and dependable attendance is required.
Performs additional tasks as assigned by management.
Level II (in addition to Level I Responsibilities)
Leads outreach efforts to internal departments to enhance quality improvements, including community-wide initiatives.

Proactively investigates best practices with other Health Plans to assess current programs, processes, and conduct rapid tests of change as necessary.

Acts as a subject matter expert on HEDIS/QARR/QRS processes and metrics, proactively reaching out to educate both internal and external stakeholders.

Reviews quality data in collaboration with Quality Measurement analysts to evaluate measure performance.

Conducts research on medical best practices, barriers, and root cause analysis for identified high-impact quality measures to pinpoint potential interventions for members or providers.

Prepares and delivers outcome reports on program activities and performance to internal and external stakeholders as required.
Anticipates regulatory changes through engagement with NCQA, CMS, and NYS DOH and addresses them accordingly.
Leads process improvements and presents results on program activities and overall performance.

Collaborates with other Health Plans, government payers, consultants, providers, BCBSA, and other healthcare entities to identify and implement best practices related to HEDIS hybrid reviews, quality, and performance improvement initiatives, programs, and benchmarks.


Minimum Qualifications:

NOTE:

This position includes multiple classification levels differentiated by demonstrated knowledge, skills, and the capacity to manage increasingly independent and/or complex assignments, broader responsibilities, additional decision-making, and in some instances, serving as a resource to others.

This differentiated approach not only facilitates the placement of new hires but also provides guidance for employee development and promotional opportunities.

All Levels
A minimum of five years of experience in healthcare is required.
A Bachelor's degree in a relevant field is required.

In lieu of a degree, a minimum of five years of progressive experience in a healthcare ambulatory setting or a health-related insurance role is acceptable.

A current Registered Nurse license in New York State or Certified Professional Coder certification is required.
Maintains a comprehensive working knowledge of HEDIS/QARR/QRS metrics.

Possesses a current and thorough understanding of federal and state regulations and advancements from quality improvement organizations, including but not limited to NCQA, CMS, and NYS DOH requirements.

Knowledge of quality improvement methodologies.
Familiarity with health plans and physician offices.
Strong problem-solving abilities. Capacity to verify data accuracy for reporting purposes.
Excellent written and verbal communication skills. Strong interpersonal and presentation capabilities.
Proficient in all Microsoft Office applications and databases for quality reporting.
Able to work independently as well as collaboratively within intra- and inter-departmental teams.
Demonstrates the ability to interact with all management levels.
Experience working with medical directors, providers, legal staff, NYS DOH, and federal regulators is essential.
A robust healthcare background to guide problem-solving related to quality issues.
Research skills to assist with the information gathering necessary to resolve quality of care cases.
Level II (in addition to Level I Qualifications)
A minimum of three years of progressive experience in HEDIS QARR QRS is required.
Demonstrates experience collaborating with providers, vendors, external regulators, and Certified NCQA auditors.
Recognized as a subject matter expert in HEDIS/QARR/QRS.
Exhibits strong organizational and planning skills. Ability to identify problems and prioritize impact or corrective actions to drive execution.
Knowledge of regulatory programs and the health insurance sector.
A seasoned professional with highly developed critical thinking skills who can engage with internal departments, external regulators, and providers.

Physical Requirements:


Ability to work while sitting and/or standing at a workstation using a computer and keyboard, mouse, and/or phone for extended periods.

Typical office environment with fluorescent lighting.
Ability to work from home for extended periods for business continuity.
Must possess a valid Class D license and the ability to operate a motor vehicle.
Ability to hear, understand, and communicate clearly while using a phone, with or without a headset.
Ability to travel across the Health Plan service region for meetings and/or training as necessary.
Ability to lift, carry, push, or pull up to 30 pounds.
Repetitive motion required (i.e., keystrokes and computer mouse movements).

One Mission. One Vision. One I.D.E.A. One you.
Together we can create a better I.D.E.A. for our communities.

At Excellus Health Plan Inc., we are committed to enhancing the health of our communities, and we rely on your support.

We recognize that diversity fuels our mission, which is why we approach our work with an I.D.E.A. mindset (Inclusion, Diversity, Equity, and Access). By leveraging our employees' experiences, skills, and perspectives, we take meaningful steps toward achieving greater health equity.

We aspire to reflect the communities we serve and strongly encourage individuals from diverse backgrounds, including people of color, LGBTQ individuals, people with disabilities, veterans, and other underrepresented groups to apply.


OUR COMPANY CULTURE:


Employees are united by our Lifetime Way Values & Behaviors, which include compassion, pride, excellence, innovation, and enjoyment. We strive to be an employer of choice by valuing workforce diversity, fostering innovative thinking, supporting employee development, and offering competitive compensation and benefits.

In accordance with the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Compensation Range(s):

Grade 113:
Minimum $ Maximum $43.02
The salary range indicated in this posting represents the minimum and maximum of the salary range for this position.

Actual salary will vary depending on factors including, but not limited to, budget availability, prior experience, knowledge, skills, and education as they relate to the position's minimum qualifications, in addition to internal equity.

The posted salary range reflects just one component of our total rewards package.

Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plans, wellness programs, paid time off, and paid holidays.


Please note:
There may be opportunities for remote work within all jobs posted by the Excellus Talent Acquisition team. This decision is made on a case-by-case basis.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Equal Opportunity Employer - minorities/females/veterans/individuals with disabilities/sexual orientation/gender identity

Minimum Salary: 0.00
Maximum Salary: 0.00

Salary Unit:
Yearly