HEDIS Quality Specialist

4 days ago

Miami, Florida, United States Borinquen Health Care Center Full time
HEDIS Specialist Job Description

Borinquen Medical Centers is seeking a full-time HEDIS Specialist to support our quality initiatives.

This role is responsible for ensuring compliance with HEDIS & P4P measures by communicating provider participation information to internal and external customers. The HEDIS Specialist will verify and update patient registration information, including insurance, demographic, and patient data. They will work collaboratively with all departments to resolve registration issues and support QI, Policy & Procedures, and the Care team.

The HEDIS Specialist will be responsible for ensuring patients comply with disease management goals, documenting in the E.H.R. to ensure continuity of care. They will provide reports on these activities on a daily, weekly, and monthly basis to the QI Manager, dependent on the E.H.R. data entered and HEDIS.

Key Responsibilities:
  • Coordinating and completing HEDIS quality specific projects ensuring consistency with BMC strategy, commitments, and goals.
  • Obtaining patient roster from participating health insurance plans.
  • Calling patients to set appointments, evaluating Quality Management Tab, Avhana & HEDIS.
  • Validating roster, scheduling appointments, and ensuring compliance with quality measures.
  • Tracking quality measures and selling BHCC services if needed, determining reason for appointment.
  • Tracking Medicare population utilization.
  • Assisting with Chronic Care management (CCM) Share medical Appointments, Complete Care Gaps, Assist with group visit.
  • Tracking hospitalization discharges and bringing patients for continuity of care.
  • Proactively seeking resources to identify gaps on existing or quality projects as they arise.
  • Performing other analyses to assist with documentation.
  • Periodically auditing records to confirm compliance with HEDIS and NCQA standards.

The HEDIS Specialist will ensure that all scheduled and tracking attended patients fulfill their care gaps and documents barriers of patients to do so. They will be responsible for verifying and updating patient registration information, including insurance, demographic, and patient data when scheduling appointments. The HEDIS Specialist will maintain internal rosters to mitigate inadvertent leakage resulting from incorrect listings.

Requirements:
  • Associate's college degree.
  • Well-organized and bilingual (Spanish and/or Creole).
  • Computer literacy with proficiency and expertise in Microsoft Office, including Outlook, Word, and Excel.
  • Ability to interact effectively with patients, administration, faculty, and staff.
  • Handle information with a high level of confidentiality.
  • Considerable knowledge of standard concepts, practices, and procedures within a field.
  • Relies on limited experience and judgment to make decisions, plan, and accomplish goals.
  • Minimum 1 year of customer service.
  • Strong interpersonal skills.
  • Bachelor's Degree.
  • Experience in a clinical background setting (LPN, MA) with case management experience.

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