Establishes and fosters a healthy working relationship with a levels of physician practices, IPAs, hospitals 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. Serves as a market clinical subject matter expert in the field, for 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. Provides coaching and training to new and current Quality Practice Advisors. Assists management with special projects and implementing new initiatives towards better best practice within the department as it pertains to day to day operations and technical resources.
Department: Dir, Quality Improvement
Reports to: Health Service QI
Additional Responsibilities:Candidate Education:
- Advises and educates all levels of 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 coaches providers on gap closing opportunities. Identifies specific practice needs where WellCare can provide support.
- Develops, enhances and maintains provider clinical relationships 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 to encourage member clinical participation in wellness and education.
- Provides resources and educational opportunities to provider and staff.
- Captures concerns/issues in action plans as agreed upon by Provider. Documents action plans and details of visits and outcomes.
- Communicates with external data sources as needed to gather data necessary to measure identified outcomes.
- Functions as HEDIS subject matter expert in consultation with provider practices.
- Conducts internal auditing for provider compliance with regulatory and NCQA accreditation standards, and monitors and provides consultation to departments to correct deficiencies.
- Ensures accuracy in medical records for data collection, data entry and reporting. Enters documentation of findings in identified databases.
- Conducts additional ad hoc QI audits through medical record review. Provides education for providers around individual state regulatory requirements, health laws, and reporting requirements.
- Assists with implementation of new and expanding health care QI/HEDIS initiatives.
- Assists in implementation of market specific strategies that improve on the quality and outcomes of member's care.
- Represents supervisors and management in meetings or on special assignments.
- Helps establish process improvements leading to best practice and assist in implementing change movement within the department.
- Trains, mentors and provides guidance to new and current Quality Practice Advisors regarding policy and procedure, systemic tools, workload and care plan development.
- Conducts audits and chart reviews on fellow Quality Practice Advisors to ensure best practice and proper protocol.
- Supports quality improvement HEDIS and program studies as needed, requesting records from providers, maintaining databases, and researching to identify members' provider encounter history.
- Maintains HIPAA standards and confidentiality of protected health information. Reports critical incidents and information regarding quality of care issues.
- 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 or coordinates with other department projects as needed.
- 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.
- Performs other duties as assigned.
- Required A Bachelor's Degree in Healthcare, Public Health, Nursing, Psychology, Health Administration, Social Work or related field
- Required or equivalent work experience directly related HEDIS record collection with analytical review/evaluation and / or Quality Improvement
- Preferred A Master's Degree in Healthcare, Public Health, Nursing, Psychology, Health Administration, Social Work or related field
- Required 4 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 3 years of experience in managed care
Licenses and Certifications:
- Advanced Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
- Advanced Demonstrated interpersonal/verbal communication skills
- Intermediate Ability to multi-task
- Intermediate Ability to work in a fast paced environment with changing priorities
- Intermediate Ability to implement process improvements
- Advanced Ability to effectively present information and respond to questions from families, members, and providers
- Advanced Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Advanced Ability to effectively present information and respond to questions from peers and management
- Advanced Ability to influence internal and external constituents
- Advanced Demonstrated analytical skills
- Advanced Knowledge of healthcare delivery
- Advanced Demonstrated organizational skills
- Advanced Demonstrated customer service skills
- Advanced Ability to analyze information and covert related activities into a comprehensive work plan
- Advanced Other Understanding of data analysis and continuous quality improvement process
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 Mental Health Counselor (LMHC)
- Required Licensed Registered Nurse (RN)
- Required Licensed Clinical Social Worker (LCSW)
- Required Licensed Marital and Family Therapist (LMFT)
- Required Licensed Master Social Work (LMSW)
- Required Acute Care Nurse Practitioner (APRN) (ACNP-BC)
- Required Licensed Vocational Nurse (LVN)
- 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)
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft Access
- Required Intermediate Microsoft PowerPoint
- Required Intermediate Microsoft Outlook
- Required Intermediate Healthcare Management Systems (Generic)