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.
DEPARTMENT: Quality Improvement
POSTION AVAILABLE IN: Chicago, Waukegan, Springfield, Bellevue and the quad-cities Moline/Davenport/Bettendorf/Rock Island areas.
- 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.
This position is contingent upon the bid award in the state of Illinois to WellCare Health Plans, Inc.
- A Bachelor's Degree in Healthcare, Public Health, Nursing, Psychology, Health Administration, Social Work or related field OR equivalent work experience of directly related HEDIS record collection with analytical review/evaluation and / or Quality Improvement required.
- A Master's Degree in Healthcare, Public Health, Nursing, Psychology, Health Administration, Social Work or related field preferred.
- 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 required.
- Managed care experience preferred.
Licenses and Certifications:
- Intermediate - Demonstrated interpersonal/verbal communication skills
- Beginner - Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
- 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 - Understanding of data analysis and continuous quality improvement process
A license in one of the following is required:
- Certified Coding Specialist (CCS)
- Licensed Practical Nurse (LPN)
- Licensed Master Social Work (LMSW)
- Licensed Vocational Nurse (LVN)
- Licensed Mental Health Counselor (LMHC)
- Licensed Marital and Family Therapist (LMFT)
- Licensed Certified Social Worker (LCSW)
- Licensed Registered Nurse (RN)
- Acute Care Nurse Practitioner (APRN) (ACNP-BC)
- Foreign trained physician/MD
The following are preferred:
- Health Care Quality and Management (HCQM)
- Certified Healthcare Professional (CHP)
- Certified Professional in Healthcare Quality (CPHQ)
- Intermediate proficiency in Microsoft Outlook, Word, Excel, and PowerPoint
- Intermediate proficiency in a Healthcare Management Systems