Under the direction of the Quality Manager, assists the Quality department in coordinating, developing, implementing, and maintaining the health plan regulatory requirements for HEDIS, NCQA, CMS and DOI improvement programs. This position will participate in the development of policies and procedures, standard work and educational materials for staff, members, and network providers to support and focus on increased performance based on data surrounding the regulatory quality improvement initiatives, and proper medical record documentation. Additionally, this person will be member facing coordinating/educating care gap closure and in the completion of selected care gaps such as Retinal Eye Exams, Bone Density Screenings, Diabetic Screenings, etc.
This position will be primarily responsible for the collection and confirmation of accuracy of documentation to support HEDIS and CMS Star Ratings. The Quality Performance Specialist will work with healthcare providers to retrieve records to be submitted to the certified HEDIS data collection vendor proactively throughout the year. This position will also be a lead resource during the annual HEDIS audit.
This position will assist 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. The Quality Performance Specialist will collaborate with the health plan Quality Team and Outreach Coordinators in care gap outreach initiatives.
The Quality Performance Specialist will support the Quality Program to ensure compliance with regulatory programs (HEDIS, Stars), accreditation standards (URAC, NCQA), and internal policies/procedures. This position will serve as a resource to support the Quality team in the general development of quality improvement programs including, but not limited to, assist in the development and oversight of HEDIS workflows, monitoring/trending data for Quality Improvement Plans, collaboration and education to networked providers regarding Quality Care Plus, HEDIS, and CMS Star Ratings.
Nature and Scope
The position will provide support the development, implementation, compliance and oversight of Hometown Health’s regulatory quality improvement programs. Components of this position include URAC & NCQA accreditation, CMS Stars, HEDIS, and member satisfaction. This position will perform other duties as requested.
The essential functions of the position are:
• Collaborate and assisting with education to providers, office staff and internal stakeholders to increase engagement on all health plan performance initiatives that support regulatory requirements for programs such as HEDIS, CAHPS and CMS Star ratings.
• Ability to maintain effective working relationships with internal staff, physicians, other providers, staff, employers, regulatory agencies, and enrollees.
• Support and implement quality improvement initiatives to improve quality outcomes related to the HEDIS audit
• Requests and evaluates reports for member compliance and improvement opportunities in each HEDIS measure.
• Audits patient charts and implements surveillance activities to ensure all quality and regulatory standards are being met.
• Provide project management for Proactive and retroactive HEDIS Audit
• Identify the unique health care needs of individuals in targeted cohorts.
• Advise members on issues related to diagnostic/preventive screenings, such as breast cancer screening, colorectal, or diabetes screenings. Also advising on issues related to improving general health in regards to nutrition and physical activity
• Communicate with members in person, by phone, or in writing.
• Perform preventative screenings within the scope of your licensure and/or training, such as Retinal Eye Scans, Bone Density Scans, Lab Collection, etc.
• Actively participates in the planning, data collection, member medical history prep of all Quality Improvement Wellness Screening Events. Performs medical screenings during events.
• Able to drive locally to complete preventive screenings or collect medical record documentation
• Ability to work independently with minimal supervision
• This position shall participate all in quality improvement and change management procedures and processes
This position does provide patient care
The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.
Requirements – Required and/or Preferred
Must have working-level knowledge of the English language, including reading, writing and speaking English.
MA license (CMA, RMA), Certified Nursing Assistant (CNA) or Public Health related degree preferred.
Requires two years of experience in a position involving public health or patient care.
Experience with HEDIS, NCQA, CMS Stars and Member Engagement is preferred.
Experience working with the Medicare population in a Health Plan setting is preferred.
Knowledge of Medical Terminology Required
Medical Assistant (CMA, RMA) or Certified Nursing Assistant (CNA) preferred
Computer / Typing:
Must possess, or be able to obtain within 90 days, the computers skills necessary to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.