Patient Care and HEDIS Quality Coordinator

Works with members and providers to close care gaps, ensure barriers to care are removed, and improve the overall member and provider experience through outreach and face-to-face interaction with members and providers at large IPA and/or group practices. Serves to collaborate with providers in the field, to improve HEDIS measures and provides education for HEDIS measures and coding. Supports the implementation of quality improvement interventions and audits in relation to plan providers. Assists in resolving deficiencies impacting plan compliance to meeting State and Federal standards for HEDIS. Conducts telephonic outreach, while embedded in the providers' offices, to members who are identified as needing preventive services in support of quality initiatives and regulatory/contractual requirements. Provides education to members regarding the care gaps they have when in the providers office for medical appointments. Schedules doctor appointments on behalf of the practitioner and assists member with wraparound services such as arranging transportation, connecting them with community-based resources and other affinity programs as available. Maintains confidentiality of business and protected health information.

Department: Quality Improvement

Location: Jackson, MS

Reports to: Corporate Medical Director



Essential Functions:
  • Acts as a liaison and member advocate between the member/family, physician and facilities/agencies.
  • Acts as the face of WellCare in the provider community with the provider and office staff where their services are embedded.
  • Advises and educates Provider practices in appropriate HEDIS measures, and HEDIS ICD-10 /CPT coding in accordance with NCQA requirements.
  • Assesses provider performance data to identify and strategizes opportunities for provider improvement.
  • Collaborates with Provider Relations to improve provider performance in areas of Quality, Risk Adjustment, Operations (claims and encounters).
  • Schedules doctor appointments for members with care gaps to access needed preventive care services and close gaps in care in the provider’s office.
  • Conducts face-to-face education with the member and their family, in the provider’s office, about care gaps identified, and barriers to care.
  • Conducts telephonic outreach and health coaching to members to support quality improvement, regulatory and contractual requirements.
  • Arranges transportation for members as needed.
  • Arranges follow-up appointments for member as needed.
  • Documents all actions taken regarding contact related to member.
  • Interacts with other departments including customer service to resolve member issues.
  • Refers to case or disease management as appropriate.
  • Completes special assignments and projects instrumental to the function of the department.
  • Performs other duties as assigned.
Additional Responsibilities:
  • Position may be located in a provider's office
Candidate Education:
  • Required A Bachelor's Degree in Healthcare, Public Health, Nursing, psychology, Social Work, Health Administration, or related health field or equivalent work experience (a total of 4 years of experience required for the position); Work experience should be in direct patient care, social work, quality improvement or health coaching preferably in a managed care environment.
Candidate Experience:
  • Required 2 years of experience in Work experience should be in direct patient care, social work, quality improvement or health coaching preferably in a managed care environment
Candidate Skills:
  • Intermediate Demonstrated interpersonal/verbal communication skills
  • Intermediate Demonstrated written communication skills
  • Intermediate Ability to create, review and interpret treatment plans
  • Intermediate Ability to effectively present information and respond to questions from families, members, and providers
  • Intermediate Ability to multi-task
  • Intermediate Ability to work in a fast paced environment with changing priorities
  • Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
  • Intermediate Ability to analyze and interpret financial data in order to coordinate the preparation of financial records
  • Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
  • Intermediate Demonstrated organizational skills
  • Intermediate Ability to work independently
  • Intermediate Knowledge of healthcare delivery
  • Intermediate Other Appreciation and sensitivity towards cultural diversity and targeted populations
Licenses and Certifications:
A license in one of the following is required:
  • Preferred Licensed Practical Nurse (LPN)
  • Preferred Licensed Master Social Work (LMSW)
  • Preferred Certified Social Worker (C-SW)
  • Preferred Licensed Social Worker (LSW)
  • Preferred Licensed Registered Nurse (RN)
Technical Skills:
  • Required Intermediate Microsoft Word Proficient in Microsoft Office such as Word, Excel and Outlook
  • Required Intermediate Microsoft Excel Ability to use and navigate health service management systems
  • Required Intermediate Microsoft Outlook
  • Required Intermediate Healthcare Management Systems (Generic)
Languages:
  • Preferred Spanish

About us
Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses exclusively on providing government-sponsored managed care services through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans to families, children, seniors and individuals with complex medical needs. WellCare is a Fortune 500 company, and in 2018, was recognized as a Fortune "World's Most Admired Company", ranking in the top five among the health insurance and managed care industry-a testament to the hard work and dedication of the company's nearly 9,000 associates who each day live WellCare's values and deliver on its mission to help its members live better, healthier lives. The company serves approximately 4.4 million members nationwide as of Dec. 31, 2017. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.