Job Profile Summary Position Purpose:
Perform duties to ensure HEDIS data accuracy and reporting, including investigation, auditing, and improvement opportunities. Assist with quality improvement initiatives in the service and clinical areas.
Education/Experience:
Bachelor’s degree in related field or equivalent experience. 3+ years of quality improvement or healthcare related experience. Working knowledge of the National Committee on Quality Assurance (NCQA). HEDIS requirements preferred.
For the Nevada Silver Summit Health Plan only:
Driver's license required.
For Health Net Federal Services only:
Government Security/Clearance/US Citizenship Requirements.
Responsibilities:
Coordinate, complete, and update management on clinical quality metrics and HEDIS processes and results.
Establish and maintain an action plan to improve HEDIS scores.
Implement process to request and evaluate member compliance reports for each HEDIS measure, including evaluating improvement opportunities.
Collaborate with providers and internal departments on rate investigation and validation activities, including maintaining all evidence, documentation, and changes.
Manage the HEDIS project to include assignment of nurses, adherence to plan timeline, and vendor oversight for timeliness and quality.
Conduct quality audit and maintain all data and process controls to ensure compliance.
Performs other duties as assigned.
Complies with all policies and standards.
EEO Statement:
Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.
Story Behind the Need – Business Group & Key Projects
Health plan or business unit
Team culture
Surrounding team & key projects
Purpose of this team
Reason for the request
Motivators for this need
Any additional upcoming hiring needs?
Need for tempo pieno support for HEDIS hybrid season:
Working with a team of 15-20 for tri-state HEDIS hybrid medical record requests. Incoming records per day 80-250 depending on workload. Possible provider office outreach – via phone. No member contact.
Required Applications:
Excel, Outlook, Teams, Word, Faxcom, OneDrive, Adobe editing skills (PDF).
Typical Day in the Role
Daily schedule & OT expectations
Typical task breakdown and rhythm
Interaction level with team
Work environment description
See above information provided for schedule and OT breakdown.
Duties include:
Monitor/manage incoming medical records – including sorting, splitting, filing of incoming records.
Investigate and contact providers to confirm demographic information and request medical records.
Review claims database for evidence of date of service.
Potential for rate max of medical records for compliance with HEDIS standards (depending on experience).
Compelling Story & Candidate Value Proposition
What makes this role interesting?
Points about team culture
Competitive market comparison
Unique selling points
Value added or experience gained
Candidate Requirements Education/Certification:
High School Diploma Preferred: Bachelor’s degree in related field or equivalent experience.
Licensure:
N/A Preferred.
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