To be fully engaged in providing Uncompromised Safety, Superior Quality, Delightful Patient/Customer Experiences, and Financial Stewardship by contributing to Health First Health Plans HEDIS activities that support regulatory compliance, CMS STARS, NCQA Accreditation and other Revenue Operations clinical quality improvement programs. The individual will assist in coordination of data collection of HEDIS and state-mandated quality metrics specification, abstraction, data entry, auditing and clinical chart review as well as identifying processes that enhance improvement in quality programs and the care of HFHP membership.
- Consistently maintain up to date standards for CMS and AHCA guidelines, and NCQA specifications, updates and benchmarks.
- Responsible for ongoing data collection, abstraction, data entry, and Performance improvement activities at the Health plan and reports to Supervisor of HEDIS.
- Maintain current knowledge of HEDIS and state-mandated quality metrics specifications, and proficiency with the vendor's reporting software to provide analytic support with data quality review, care gap analysis and reports.
- Support quality improvement programs and studies by requesting records from providers, maintaining databases, and researching health plan encounter data on an ongoing basis.
- Assist with tracking data for clinical and non-clinical quality performance improvement activities.
- Participate in and represent the health plan at community and other organizational meetings focusing on quality improvement, member education, care gap completion, risk reduction and other areas as assigned.
- Perform continuing medical record evaluation and follow-up education as required.
- Develop relationships with key individuals (externally and internally) to foster an increased understanding of the HEDIS and Risk Adjustment process.
- Participate in special projects as requested by leadership and assist in identifying opportunities for operational improvements consisted with Health First and Revenue Operations strategic goals.
- Accurately review, abstract, data enter and overread HEDIS data from qualified medical records per established guidelines and internal protocols.
- Assist in process improvement implementation to maximize STARS ratings.
- Ensure financial impact to organization as well as data submitted for Risk adjustment and HEDIS measures is complete, accurate and thorough to mitigate risk of regulatory agency audits.
- Gain a thorough understanding of the Risk Adjustment payment methodology, submission requirements and their impact to the Health First Health Plans payments
MINIMUM QUALIFICATIONS REQUIRED:
- Certifications required within the first year of employment: Certified Professional Coder (CPC) Professional Academy for Health Management (PAHM)
- 3 years experience in health care, clinical quality or related work experience.
- Must have proficiency in health care related applications, EMR, Word, Excel, and a basic understanding of database management.
- Must be able to abstract data, and present data in clear reporting formats to support comparison and analysis.
- Knowledge base of clinical standards of care, preventive health standards, HEDIS, NCQA, governing and regulatory agency requirements, and the managed care industry.
- Must have solid mathematical skills, and demonstrate accuracy in tabulation of data and
calculation of rates based on defined numerators/denominators.
- Must have analytical skills sufficient to assess and identify variations in data and processes.
- Ability to evaluate medical records and data with attention to detail
- Intermediate knowledge of Risk Adjustment and/or HEDIS.
- Exceptional interpersonal relationship skills.
- Demonstrates excellent written and verbal communication skills conforming to all rules of punctuation, grammar, diction and professional style.
- Presents professional image to the public.
- Experience monitoring policies, internal control procedures and operating standards.
- Ability to navigate constructive conversations on behalf of the health plan with State and Federal officials.
- Bachelor's degree in Health Sciences or related field
- One or more years in Managed Care setting or Quality Improvement experience preferred.
- Ability to work flexible and/or long hours at a desk using computers, telephone and a variety of other automated office machines.
- Ability to handle work in various office environments.
- Ability to handle multiple tasks with limited time schedules.
- Function well under stress.
- Must be flexible.
- Ability to manage and prioritize responsibilities and goals.
COMPETENCY ASSESSMENT/SKILLS CHECKLIST:
- 95%-98% Abstraction and Data Entry Accuracy Rate
- Consistently meet productivity goals
- Complete CPC and PAHM within 1 year of hire