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: Health Services
Location: Cypress, CA
Reports To: Director of Quality Improvement
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.
Required A Bachelor's Degree in Healthcare, Public Health, Nursing, Psychology, Health Administration, Social Work or related field
Required or equivalent work experience within a managed care environment related to HEDIS record review, quality improvement, medical coding or transferable skill sets that demonstrates the ability to perform the role
Preferred A Master's Degree in Healthcare, Public Health, Nursing, Psychology, Health Administration, Social Work or related field
Required 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.
Preferred Other Managed care experience
Intermediate Demonstrated interpersonal/verbal communication skills
Beginner Ability to analyze and interpret financial data in order to coordinate the preparation of financial records
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 Other Understanding of data analysis and continuous quality improvement process
Licenses and Certifications: A license in one of the following is required:
Preferred Other One of the following licenses is strongly preferred:
Preferred Certified Coding Specialist (CCS)
Preferred Licensed Practical Nurse (LPN)
Preferred Licensed Master Social Work (LMSW)
Preferred Licensed Vocational Nurse (LVN)
Preferred Licensed Mental Health Counselor (LMHC)
Preferred Licensed Marital and Family Therapist (LMFT)
Preferred Licensed Certified Social Worker (LCSW)
Preferred Licensed Registered Nurse (RN)
Preferred Acute Care Nurse Practitioner (APRN) (ACNP-BC)
Preferred 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 Word
Required Beginner Microsoft PowerPoint
Required Intermediate Microsoft Outlook
Required Beginner Healthcare Management Systems (Generic)