Quality Outreach Specialist - Pharmacy at Emblem Health in Farmington, Connecticut

Job Description:

Summary:

Perform provider and member outreach to reconcile member records and validate data entry to support continuous quality improvement in Healthcare Effectiveness Data and Information Set (HEDIS) rates and STAR measures for the enterprise. Facilitate provider and member outreach supporting the MTM, OMW quality measures and the Comprehensive Medication Management Program to ensure member receipt of important clinical services to improve member health outcomes. Daily telephonic outreach to secure appointments with pharmacists and/or vendors to close gaps in care. Support efficient medical record retrieval for HEDIS medical record review and HEDIS supplemental data collection activities. Track calls for all lines of business related to the MTM, OMW quality measures and the Comprehensive Medication Management Program, reporting weekly completion statistics. Produce and process department mailings to members and physicians. Monitor internal mailboxes for department faxes and calls. Collaborate with internal departments in order to administer the MTM, OMW quality measures and the Comprehensive Medication Management Program

Responsibilities:

• Work closely with Clinical Pharmacist(s), Registered Nurses and Data Analyst(s) to prioritize members for outreach who fall in HEDIS measures including but not limited to OMW (Osteoporosis Management in Women who had a fracture), MTM (Medication Therapy Management) Program and Comprehensive Medication Management Program addressing medication adherence and barriers to care.
• Perform daily telephonic outreach to secure appointments with pharmacists and/or vendors to close gaps in care supporting Enterprise goals.
• Perform daily provider and member outreach supporting the MTM, OMW quality measures and Comprehensive
• Medication Management Program to ensure member receipt of important clinical services to improve member health outcomes.
• Prepare and execute member and provider mailings.
• Collaborate with providers and internal departments to ensure the receipt and correct processing of all supplemental data related to HEDIS claims and records and assist in correcting discrepancies.
• Maintain high data integrity while adhering to HIPAA standards and protecting patient information.
• Perform provider outreach to verify and document member’s appropriate medical diagnoses and subsequent treatments both by telephone and in writing.
• Coordinate call tracking and provide statistics to stakeholders
• Intake and organize data from other departments while ensuring proper compliance with all CMS regulations, policies and procedures.

Qualifications:

• High School Diploma, Required
• College Degree, Preferred
• Pharmacy Technician License, Preferred
• Minimum of 1-year direct customer service experience in a healthcare setting required
• Excellent telephonic and customer service skills required
• Experience analyzing data and building action plans based upon data outcomes required
• Personal motivation to achieve set goals required
• Flexibility and ability to adjust workflow to achieve company goals required
• Experience with or knowledge of Electronic Medical Records preferred
• Knowledge of or experience with HEDIS, STAR ratings, and/or quality improvement preferred
• Experience in a managed care health services environment preferred
• Experience in data collection, data entry and analysis preferred
• Knowledge of Excel and other analytical tools preferred

Additional Information

• Requisition ID: 2112A