Quality Practice Advisor, Associate - Hattiesburg, MS

Establishes and fosters a healthy working relationship between community physician and small provider practices and WellCare. Educates providers and supports provider practice sites in regards to the National Committee for Quality Assurance (NCQA) HEDIS measures. Provides education for HEDIS measures, appropriate medical record documentation and appropriate coding. Assists in resolving deficiencies impacting plan compliance to meet State and Federal standards for HEDIS.

Reports To: Director, ACO

Department: Health Services

Position Location: Hattiesburg, MS 39401

Essential Functions:

  • Under general guidance form Senior Quality Practice Advisors and management, educates community physician and small provider practices in appropriate HEDIS measures, medical record documentation guidelines and HEDIS ICD-9/10 CPT coding in accordance with NCQA requirements.
  • Collects, summarizes and trends provider performance data to identify and strategize opportunities for provider improvement.
  • Collaborates with Provider Relations to improve provider performance in areas of Quality, Risk Adjustment and Operations (claims and encounters).
  • Assists in delivering provider specific metrics and coaches providers on gap closing opportunities.
  • Assists in identifying specific practice needs where WellCare can provide support.
  • Partners with physicians/physician staff to find ways to encourage member clinical participation in wellness and education.
  • Provides resources and educational opportunities to provider and staff.
  • Captures concerns and issues in action plans as agreed upon with provider.
  • Documents action plans and details of visits and outcomes. Reports critical incidents and information regarding quality of care issues.
  • 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.
  • Supports quality improvement HEDIS and program studies as needed, requesting records from providers, maintaining databases, and researching to identify members' provider encounter history.
  • 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.
  • Enter documentation of findings in identified databases and ensure accuracy in medical records for data collection, DE and reporting.
  • Performs other duties as assigned.
Additional Responsibilities:
    Candidate Education:
    • Required A Bachelor's Degree in Healthcare, Public Health, Nursing, Psychology, Health Administration, Social Work or related field
    • Required or equivalent work experience within a managed care environment related to HEDIS record review, quality improvement, medical coding or transferable skill sets that demonstrates the ability to perform the role
    • Preferred A Master's Degree in Healthcare, Public Health, Nursing, Psychology, Health Administration, Social Work or related field
    • Required Other If no clinical license, must have a Master's Degree in Healthcare, Public Health, Health Administration, Social Work or related field and 2 years of specific HEDIS experience directly related to the duties of the job
    Candidate Experience:
    • Required 1 year of experience in related HEDIS medical record review or quality improvement with experience in data and chart reviews to provide consultation and education to providers and provider staff OR 2 years medical coding or other transferable experience and skill set combination that demonstrates the ability to learn and perform the level of the position OR 2 years of directly related experience and a Master's Degree in a related field required if not licensed
    • Preferred Other Managed care experience
    Candidate Skills:
    • Intermediate Demonstrated interpersonal/verbal communication skills
    • Beginner Ability to analyze and interpret financial data in order to coordinate the preparation of financial records
    • 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 effectively present information and respond to questions from families, members, and providers
    • Intermediate Ability to influence internal and external constituents
    • Intermediate Ability to effectively present information and respond to questions from peers and management
    • Intermediate Demonstrated analytical skills
    • Intermediate Ability to represent the company with external constituents
    • Beginner Other Understanding of data analysis and continuous quality improvement process
    Licenses and Certifications:
    A license in one of the following is required:
    • Other One of the following licenses is required:
    • Required Certified Coding Specialist (CCS)
    • Required Licensed Practical Nurse (LPN)
    • Required Licensed Master Social Work (LMSW)
    • Required Licensed Vocational Nurse (LVN)
    • Required Licensed Mental Health Counselor (LMHC)
    • Required Licensed Marital and Family Therapist (LMFT)
    • Required Licensed Certified Social Worker (LCSW)
    • Required Licensed Registered Nurse (RN)
    • Required Acute Care Nurse Practitioner (APRN) (ACNP-BC)
    • Required Other Foreign trained physician/MD
    • Preferred Health Care Quality and Management (HCQM)
    • Preferred Certified Healthcare Professional (CHP)
    • Preferred Certified Professional in Healthcare Quality (CPHQ)
    Technical Skills:
    • Required Intermediate Microsoft Excel
    • Required Intermediate Microsoft Word
    • Required Beginner Microsoft PowerPoint
    • Required Intermediate Microsoft Outlook
    • Required Beginner Healthcare Management Systems (Generic)

      About us
      Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. 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.