QI SPECIALIST II (HEDIS)

Job description

Location: Irving, TX Duration: 3+ Months (Temp to Perm) Duration: Possibility to be extended beyond initial 90 days and if the agent has great attendance and performance. In addition, they will be evaluated for a potential perm role. Bilingual is a plus but not a must. There is travel: They will be visiting local provider offices to pick up medical records or performing audits on those offices. All candidates need a valid unrestricted driver’s license. Establishes and fosters a healthy working relationship between community physician practice. Educates providers and supports provider practice sites in regards to the National Committee for Quality Assurance (NCQA) HEDIS measures. Provides education for HEDIS measures; reviews charts for appropriate medical record documentation and appropriate coding. Candidate assists in resolving deficiencies impacting plan compliance to meeting State and Federal standards for HEDIS/STAR Measures. Acts as a resource for the market on HEDIS measures, appropriate medical record documentation and appropriate coding. Candidate supports the development and implementation of quality improvement interventions and reviews in relation to plan providers. Essential Functions: • Advises and educates Provider practices in appropriate HEDIS measures, medical record documentation guidelines and HEDIS ICD-9/10 CPT coding in accordance with NCQA requirements. • Collects, summarizes and trends provider performance data to identify and strategize opportunities for provider improvement. • Collaborates with Provider Relations to improve provider performance in areas of Quality, Risk Adjustment, Operations (claims and encounters). • Delivers provider specific metrics and coach providers on gap closing opportunities. • Develops, enhances and maintains provider clinical relationship across product lines. • Leads and/or supports collaborative business partnerships, elicit client understanding and insight to advise and make recommendations. • Partners with physicians/physician staff to find ways to explore new ways to encourage member clinical participation in wellness and education. • Provides resources and educational opportunities to provider and staff. • Captures concerns/issues in action plans as agreed upon by Provider. • Documents action plans and details of visits and outcomes; reports critical incidents and information regarding quality of care issues. • Communicates with external data sources as needed to gather data necessary to measure identified outcomes. • Provides communication such as newsletter articles, member education, outreach interventions and provider education. • Coordinates and host clinic and event days to address provider/SDA missing services. • Supports quality improvement program studies and HEDIS as needed, requesting records from providers, maintaining databases, and researching to identify members' provider encounter history. • Ensures that documentation produced and/or processed complies with state regulations and/or accrediting body requirements. • Participates in and represents plan at community, health department, collaborative and other organizational meetings focusing on quality improvement, member education, and disparity programs, as assigned. • Supports QI program studies and HEDIS as needed, requesting records from providers, maintaining databases and researching to identify member’s provider history. • Ensures accuracy in medical records for data collection, data entry and reporting. Enters documentation of findings in identified databases. • Performs other duties as assigned. Candidate Education: • Bachelor's Degree in Healthcare, Public Health, Nursing, Psychology, Health Administration, Social Work or related field is required. Candidate Experience: • 2 years of experience in directly related HEDIS medical record review and/or Quality Improvement with experience in data and chart reviews to provide consultation and education to providers and provider staff is required • Care experience is preferred Candidate Skills: • Demonstrated interpersonal/verbal communication skills • Knowledge of medical terminology and/or experience with CPT and ICD-9 coding • Ability to multi-task • Ability to work in a fast paced environment with changing priorities • Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions • Ability to implement process improvements • Ability to effectively present information and respond to questions from families, members, and providers • Ability to influence internal and external constituents • Demonstrated analytical skills • Ability to analyze and interpret financial data in order to coordinate the preparation of financial records • Understanding of data analysis and continuous quality improvement process Licenses and Certifications: A license in one of the following is required: • Licensed Practical Nurse (LPN) • Licensed Registered Nurse (RN) Technical Skills: • Microsoft Excel is required • Microsoft PowerPoint is required • Microsoft Outlook is required All your information will be kept confidential according to EEO guidelines. Integrated Resources, Inc., is led by a seasoned team with combined decades in the industry. We deliver strategic workforce solutions that help you manage your talent and business more efficiently and effectively. Since launching in 1996, IRI has attracted, assembled and retained key employees who are experts in their fields. This has helped us expand into new sectors and steadily grow. We’ve stayed true to our focus of finding qualified and experienced professionals in our specialty areas. Our partner-employers know that they can rely on us to find the right match between their needs and the abilities of our top-tier candidates. By continually exceeding their expectations, we have built successful ongoing partnerships that help us stay true to our commitments of performance and integrity. Our team works hard to deliver a tailored approach for each and every client, critical in matching the right employers with the right candidates. We forge partnerships that are meant for the long term and align skills and cultures. At IRI, we know that our success is directly tied to our clients’ success.