Quality Performance Specialist

Under the direction of leadership, assists the Quality department in coordination, development, and implementation of regulatory and accreditation programs such as HEDIS, NCQA, CMS and State of Nevada quality improvement programs (QIP). This position participates in the development of policies and procedures, standard work and educational materials for staff, members, and network providers to support increased performance based on data surrounding the QIPs as well as ensuring and enforcing proper medical record documentation. Additionally, this person will be both member and provider facing coordinating & educating on regulatory quality programs and assisting in the closure of required gaps in care. The Quality Performance Specialist coordinates with both the Quality Improvement team, Risk Adjustment team, and outreach coordinators in care gap initiatives.

This position facilitates the key quality functions such as member rewards programs, provider pay for performance programs, documentation of quality outcomes, and facilitation of provider group Joint Operating Committees (JOC). This position also develops provider and member communications and education from the QI department. This role acts as a facilitator and coordinator for all formal QI committees that role up to the board of directors, while ensuring that we have met all required regulatory and accreditation requirements.

This position is responsible for the collection and confirmation of accuracy of documentation to support HEDIS and NCQA requirements. This position works with healthcare providers to retrieve supporting medical record documentation to be submitted to the certified HEDIS vendor throughout the year. This position also acts as a resource to supporting contract staff during annual HEDIS and other regulatory audits.

The essential responsibilities of the position are:

* Collaborate and coordinate education materials and programs to providers, members, and internal stakeholders to increase engagement on all health plan performance initiatives that support regulatory requirements for programs such as HEDIS, CAHPS, NCQA, URAC, CMS, and State of Nevada.

* Ability to maintain effective working relationships with internal staff, physicians, other providers, staff, employers, regulatory agencies, and enrollees.

* Provide both provider and member educational materials and programs tailored to increase compliance in targeted quality metrics.

* Support and implement quality improvement initiatives to improve quality outcomes related to the HEDIS audit and URAC/NCQA accreditation.

* Audits patient charts and implements surveillance activities to ensure all quality and regulatory standards are being met.

* Provide project management for prospective and retrospective HEDIS audit.

* Identify the unique health care needs of individuals with varying ethnic, racial, and socioeconomic needs and develop targeted interventions to bridge disparities.

* Facilitate both member rewards programs and provider pay for performance programs, including oversight and monitoring of provider compliance and performance.

* Implement system committee guidelines and facilitate the QI committee structure.

* Collaborate with providers through coordination of JOCs (both onsite and virtual) sharing data, education, and resources to meet plan goals and targets.

* Actively participates in the planning, data collection, member medical history prep of all Quality Improvement Wellness Screening. Performs preventive screenings within the scope of your licensure and/or training during events.

* Able to drive locally to complete preventive screenings or collect medical record documentation.

* This position assists in completing care gaps such as retinopathy eye exams, bone density scans, FIT tests, lab work, etc. during Hometown Health Wellness Fairs as well as at local healthcare provider office events.

* Reviews the After Visit Summary with the patient and identifies need for establishing with a primary care provider, setting up MyChart and providing a tutorial as needed.

* May be responsible for scheduling, order entry and reception functions and assists in completion of departmental tasks.

* May perform screening questionnaires telephonically with members.

* May be responsible for assisting the provider in back-office duties, including but not limited to escorting the patient from the waiting room to the examination room promptly; taking vital signs as per guidelines; maintaining examination rooms' stock; documenting all patient communications; preparing lab specimens for processing; perform Point of Care testing; administer medications per provider order in accordance with established policies.

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Name

Description

Education:

Must have working-level knowledge of the English language, including reading, writing, and speaking English. Bachelor's degree in public health or other healthcare related degree, or equivalent work experience preferred Bilingual preferred, but not required.

Experience:

Requires two years of experience in a position involving public health or patient care. Experience with regulatory programs or accreditation, such as HEDIS, NCQA or CMS is preferred. Knowledge of medical terminology required.

License(s):

None

Certification(s):

Current AHA BLS/CPR or ability to obtain within 90 days of employment required. Current Certified Medical Assistant (CMA) certification, Registered Medical Assistant (RMA), Certified Clinical Medical Assistant (CCMA), National Certified Medical Assistant (NCMA) required upon hire.

Computer / Typing:

Must possess, or be able to obtain within 90 days, the computers skills necessary to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.