This position facilitates the key quality functions such as member rewards programs, provider pay for performance programs, documentation of quality outcomes, and facilitation of provider group Joint Operating Committees (JOC). This position also develops provider and member communications and education from the QI department. This role acts as a facilitator and coordinator for all formal QI committees that role up to the board of directors, while ensuring that we have met all required regulatory and accreditation requirements.
This position is responsible for the collection and confirmation of accuracy of documentation to support HEDIS and NCQA requirements. This position works with healthcare providers to retrieve supporting medical record documentation to be submitted to the certified HEDIS vendor throughout the year. This position also acts as a resource to supporting contract staff during annual HEDIS and other regulatory audits.
The essential responsibilities of the position are:
• Collaborate and coordinate education materials and programs to providers, members, and internal stakeholders to increase engagement on all health plan performance initiatives that support regulatory requirements for programs such as HEDIS, CAHPS, NCQA, URAC, CMS, and State of Nevada.
• Ability to maintain effective working relationships with internal staff, physicians, other providers, staff, employers, regulatory agencies, and enrollees.
• Provide both provider and member educational materials and programs tailored to increase compliance in targeted quality metrics.
• Support and implement quality improvement initiatives to improve quality outcomes related to the HEDIS audit and URAC/NCQA accreditation.
• Audits patient charts and implements surveillance activities to ensure all quality and regulatory standards are being met.
• Provide project management for prospective and retrospective HEDIS audit.
• Identify the unique health care needs of individuals with varying ethnic, racial, and socioeconomic needs and develop targeted interventions to bridge disparities.
• Facilitate both member rewards programs and provider pay for performance programs, including oversight and monitoring of provider compliance and performance.
• Implement system committee guidelines and facilitate the QI committee structure.
• Collaborate with providers through coordination of JOCs (both onsite and virtual) sharing data, education, and resources to meet plan goals and targets.
• Actively participates in the planning, data collection, member medical history prep of all Quality Improvement Wellness Screening. Performs preventive screenings within the scope of your licensure and/or training during events.
• Able to drive locally to complete preventive screenings or collect medical record documentation.
• This position assists in completing care gaps such as retinopathy eye exams, bone density scans, FIT tests, lab work, etc. during Hometown Health Wellness Fairs as well as at local healthcare provider office events.
• Reviews the After Visit Summary with the patient and identifies need for establishing with a primary care provider, setting up MyChart and providing a tutorial as needed.
• May be responsible for scheduling, order entry and reception functions and assists in completion of departmental tasks.
• May perform screening questionnaires telephonically with members.
• May be responsible for assisting the provider in back-office duties, including but not limited to: escorting the patient from the waiting room to the examination room promptly; taking vital signs as per guidelines; maintaining examination rooms’ stock; documenting all patient communications; preparing lab specimens for processing; perform Point of Care testing; administer medications per provider order in accordance with established policies.