Establishes and fosters a healthy working relationship between large physician practices, IPAs 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. Acts as a resource for the market on HEDIS measures, appropriate medical record documentation and appropriate coding. Supports the development and implementation of quality improvement interventions and audits in relation to plan providers.
DEPARTMENT: Quality Improvement-Health Services
REPORTS TO: Manager, Quality Improvement
- Advises and educates large Provider practices and IPAs 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).
- Delivers provider specific metrics and coach providers on gap closing opportunities.
- Identifies specific practice needs where WellCare can provide support.
- Develops, enhances and maintains provider clinical relationship across product lines.
- Defines gaps in WellCare's service relationship with providers and facilitate resolution.
- Leads and/or supports collaborative business partnerships, elicit client understanding and insight to advise and make recommendations.
- Partners with physicians/physician staff to find ways to explore new 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 by provider.
- Documents action plans and details of visits and outcomes and 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.
- Participates in and represents plan at community, health department, collaborative and other organizational meetings focusing on quality improvement, member education, and disparity programs, as assigned.
- Ensures accuracy in medical records for data collection, data entry and reporting. Enters documentation of findings in identified databases.
- Performs other duties as assigned.
- Role will travel up to 75% of the time within assigned territory.
*LI-SM1 Candidate Education:
- Required a Bachelor's Degree in Healthcare, Public Health, Nursing, Psychology, Health Administration, Social Work or related field
- Preferred a Master's Degree in Healthcare, Public Health, Nursing, Psychology, Health Administration, Social Work or related field
- Required 2 years of experience in directly related HEDIS medical record review and/or Quality Improvement with experience in data and chart reviews to provide consultation and education to providers and provider staff
- Required 1 year of experience in Managed Care experience
Licenses and Certifications:
- Intermediate demonstrated interpersonal/verbal communication skills
- Intermediate knowledge of medical terminology and/or experience with CPT and ICD-9 & 10 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 implement process improvements
- Intermediate ability to effectively present information and respond to questions from families, members, and providers
- Intermediate ability to influence internal and external constituents
- Intermediate demonstrated analytical skills
- Intermediate demonstrated customer service skills
- Intermediate ability to analyze information and covert related activities into a comprehensive work plan
- Intermediate demonstrated organizational skills
- Intermediate knowledge of healthcare delivery
- Intermediate understanding of data analysis and continuous quality improvement process
A license in one of the following is required:
- Required Certified Coding Specialist (CCS)
- Required Licensed Practical Nurse (LPN)
- Required Licensed Clinical Social Worker (LCSW)
- Required Licensed Mental Health Counselor (LMHC)
- Required Licensed Master Social Work (LMSW)
- Required Licensed Marital and Family Therapist (LMFT)
- Required Licensed Vocational Nurse (LVN)
- Required Licensed Registered Nurse (RN)
- Required Acute Care Nurse Practitioner (APRN) (ACNP-BC)
- Preferred Health Care Quality and Management (HCQM)
- Preferred Certified Healthcare Professional (CHP)
- Preferred Certified Professional in Healthcare Quality (CPHQ)
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft Outlook
- Required Intermediate Healthcare Management Systems (Generic)
- Required Intermediate Microsoft PowerPoint