The Clinical Quality Manager with members and providers to ensure members receive appropriate services. This role emphasizes improving the quality of care with a focus on HEDIS, QARR and Medicare Advantage Star measures.
* Interacts with hospitals, providers, and members to improve quality of care, monitor progress, and recommend changes
* Reviews billing codes, medical records, and claims submission process to ensure accuracy
* Attends and facilitates any initiative meetings (studies, partnerships) that involve targeted providers and/or measures.
* Completes on-site visits on a regular basis to implement the work plan and to conduct provider education sessions regarding appropriate coding practices and chart documentation.
* Collaborates with other departments to maximize member outreach for preventive services and chronic disease management.
* Assists in writing member and/or provider articles in relation to HEDIS, QARR, Medicare Advantage and/or health promotions for HF newsletter.
* Supports regulatory affairs, as deemed necessary by management.
* Documents all relevant interactions in appropriate systems
* Additional duties as assigned
* Ability to travel around the NYC metro area
* Associate's degree
* Bachelor's Degree
* Clinical license: LPN, RN, LMSW or LCSW
* Multiple years of HEDIS review experience for both Medicaid and Medicare lines of business
* Medical record review experience directly working on HEDIS/QARR in a managed care setting
* Good presentation, relationship management, and analytical skills
* Intermediate MS Word, Excel, and PowerPoint
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.
If you have a disability under the Americans with Disability Act or a similar law, and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to ...@Healthfirst.org or calling 212-###-#### . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.
EEO Law Poster and Supplement