Senior Quality Care Coordinator - HEDIS

The Senior Quality Care Coordinator develops, implements, and provides ongoing monitoring of intervention plans and quality gap closure. The overall goal of this role is to reduce medical costs, improve quality ratings, and ensure quality accreditation and CMS requirements are met. The Senior Quality Care Coordinator achieves this goal through member and/or provider engagement, internal quality process improvement work, and coordination of overall clinical and non-clinical intervention strategies. The coordinator could be the SME for HEDIS, quality, condition management, or the clinical support for the appeals and grievance process. The Senior Quality Care Coordinator oversees the overall HEDIS program and submission which includes year-round medical record reviews, and is responsible for ensuring that Network Health meets all OCI, CMS, and NCQA quality requirements.

Location: Candidates must reside in the states of WI, OH, IN, AL, or FL for consideration. This position is eligible to work at your home office (reliable internet is required), at our office in Brookfield or Menasha, or a combination of both in our hybrid workplace model.

Hours: 1.0 FTE, 40 hours per week, 8am-5pm Monday through Friday

Check out our 2024 Community Report to learn a little more about the difference our employees make in the communities we live and work in. As an employee, you will have the opportunity to work hard and have fun while getting paid to volunteer in your local neighborhood. You too, can be part of the team and making a difference. Apply to this position to learn more about our team.

Job Responsibilities:

• Demonstrate commitment and behavior aligned with the philosophy, mission, values and vision of Network Health
• Appropriately apply all organizational, regulatory, and credentialing principles, procedures, requirements, regulations, and policies
• Monitor year round HEDIS rates and provide guidance on improvement strategy.
• Oversee all aspects of the HEDIS annual submission program including but not limited to; auditor requirements, HOQ, roadmap, retrieval status monitoring, overreads, leadership status reporting, issue log, PSV, MRRV, and IDSS submission.
• Provide staff training on HEDIS measures and tools annually and as needed
• Assist with regulatory and accreditation requirements and non-standard supplemental data audits
• Provide feedback and guidance on HEDIS related questions
• Provide direct outreach to members and/or providers in order to close quality gaps and maintain or exceed expected population health outcomes per HEDIS, Stars and NCQA
• Create written materials for members, physicians, and other customers in formats such as newsletters, brochures, self-care materials, educational handouts, letters and telephone scripts
• Responsible for development and coordination of member centric programs in alignment with industry and regulatory standards
• Evaluate utilization patterns, medical records, and other metrics to monitor quality and efficiency results
• Provide clinical support for the appeals and grievance department and quality of care complaint process, preparing cases for medical director review when needed
• Identify opportunities for improvement and implement clinical interventions
• Prepare and/or deliver presentations for Quality Management committee, clinic or provider education, and system-wide committees as needed
• Lead, monitor, and document quality interventions and care management programs with goal of effectiveness that promotes value added care and service
• Collaborate closely with secondary providers and/or vendors to coordinate services for members
• Function as a liaison when needed for family, member, and provider to communicate any current of potential issues
• Develop, review, and revise department policies and procedures including preventive services requirements
• Provide recommendations for preventive services medicine and evidence based clinical guidelines, seek approval and monitor for updates or relevant changes as assigned
• Research, submit, and evaluate quality improvement projects regulated by CMS as assigned
• Implement systems of care that facilitate close monitoring of members to promote early intervention
• Other duties as assigned

Job Requirements:

• Associate or Bachelor's degree in nursing preferred
• Associate degree or Bachelor's degree with other clinical designations and relevant experience considered
• 5 or more years of clinical experience required
• Experience in data analysis, quality improvement, HEDIS program management, medical record review, preventive care required
• Health plan experience required

We are proud to be an Equal Opportunity Employer who values and maintains an environment that attracts, recruits, engages and retains a diverse workforce.