Key Duties and Responsibilities Collects data for ambulatory medical record reviews and compliance with provider preventive health and chronic disease outcome improvement interventions. Prepares reports and quality improvement studies in an accurate, concise and timely fashion. Conducts internal auditing for compliance with regulatory and accreditation standards, and monitors and provides consultation to departments to correct deficiencies. 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. Collects and summarizes performance data and identifies opportunities for provider improvement. Participates in site visit preparation and execution by regulatory and accreditation agencies (State agencies, CMS, AAAHC, URAC, NCQA,EQRO). Pursues methods to ensure receipt of data required for trending and reporting of various QI work plan metrics. Assists in activities to prioritize clinical and service improvement initiatives. Ensures that documentation produced and/or processed complies with state regulations and/or accrediting body requirements. Ensures assigned contract/regulatory report content is accurate and that submission adheres to deadline. Performs other duties as assigned.
Education Level A Bachelor's Degree in a related field or equivalent work experience
Experience Level 3+ years of experience in HEDIS and/or quality improvement -Required Experience in a managed care health services environment- Required Experience in data collection and data entry- Required
Skill Sets Knowledge of medical terminology and/or experience with CPT and ICD-9 coding Demonstrated interpersonal/verbal communication skills Ability to multi-task Ability to work in a fast paced environment with changing priorities Ability to implement process improvements Ability to effectively present information and respond to questions from families, members, and providers
Technology Microsoft Excel Microsoft Access Microsoft PowerPoint Microsoft Outlook
**HEDIS Reviewers - Can be RN / LPN / Medical Coder / Medical Records Specialist**