Senior Quality Care Coordinator - HEDIS Emphasis

Network Health's success is rooted in its mission to create healthy and strong Wisconsin communities. It drives the decisions we make, including the people we choose to join our growing team. Network Health is seeking a Senior Quality Care Coordinator. This position develops, implements and provides ongoing monitoring of intervention plans and quality gap closure. The overall goal of this role is to reduce medical costs, improve quality ratings and ensure quality accreditation and CMS requirements are met. The Sr. Quality Care coordinator achieves this goal through member and/or provider engagement, internal quality process improvement work, and coordination of overall clinical and non-clinical intervention strategies. This role will have varying areas of focus depending on business need, this coordinator could be the SME for HEDIS, quality, condition management, or the clinical support for the appeals and grievance process. The Sr. Quality Care Coordinator-oversees the overall HEDIS program and submission which includes year-round medical record reviews and is responsible for ensuring that Network Health meets all OCI, CMS and NCQA quality requirements.

Job Responsibilities:

• Provide direct outreach to members and/or providers in order to close quality gaps and maintain or exceed expected population health outcomes per HEDIS, Stars and NCQA.
• Creates written materials for members, physicians, and other customers in formats such as newsletters, brochures, self-care materials, educational handouts, letters and telephone scripts.
• Responsible for development and coordination of member centric programs in alignment with industry and regulatory standards.
• Evaluates utilization patterns, medical records and other metrics to monitor quality and efficiency results.
• Provides clinical support for the appeals and grievance department and quality of care complaint process, preparing cases for medical director review when needed.
• Identifies opportunities for improvement and implements clinical interventions.
• Prepare and/or deliver presentations for Quality Management committee, clinic or provider education, and system-wide committees as needed.
• Leads, monitors and documents quality interventions and care management programs with goal of effectiveness that promotes value added care and service.
• Collaborates closely with secondary providers and/or vendors to coordinate services for members.
• Functions as a liaison when needed for family, member and provider to communicate any current of potential issues.
• Prepares reports as necessary.
• Develop, review, and revise department policies and procedures including preventive services requirements.
• Provides recommendations for preventive services medicine and evidence based clinical guidelines, seek approval and monitor for updates or relevant changes as assigned.
• Research, submit and evaluate quality improvement projects regulated by CMS as assigned.
• Implements systems of care that facilitate close monitoring of members to promote early intervention.
• Training new employees and acting as a mentor.
• Other duties as assigned.

As a HEDIS subject matter expert, you will be responsible for:

• Monitor year round HEDIS rates and provide guidance on improvement strategy.
• Oversee all aspects of the HEDIS annual submission program including but not limited to; auditor requirements, HOQ, roadmap, retrieval status monitoring, overreads, leadership status reporting, issue log, PSV, MRRV, and IDSS submission.
• Provide staff training on HEDIS measures and tools annually and as needed
• Assist with regulatory and accreditation requirements
• Assist with non-standard supplemental data audits
• Provide feedback and guidance on HEDIS related questions

Job Requirements:

• Associate or bachelors degree in nursing preferred
• Associate degree or bachelor's degree with other clinical designations and relevant experience considered
• 5 or more years of clinical experience
• Experience in data analysis, quality improvement, HEDIS program management, medical record review, preventive care
• Health plan experience
• Preferred Registered Nurse (RN) license, Certified coder, or other medical or clinical background with credentials

We are proud to be an Equal Opportunity Employer who values and maintains an environment that attracts, recruits, engages and retains a diverse workforce.