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Job Description:

Summary:

This position is responsible for quality activities, including but not limited to HEDIS/QARR/QRS process, quality of care concerns, NCQA requirements, medical record reviews and studies required by the Health Plan in support of regulatory requirements. In addition, the quality team supports the goals, objectives, and direction of the Risk Adjustment Department.

Essential Accountabilities:

Level I

+ Assists in the completion of the extensive reporting requirements for mandated reporting, such as HEDIS/QARR/QRS.

+ Documents all processes and procedures relating to current HEDIS hybrid review plan.

+ Develops, implements, and monitors hybrid audit process to meet external audit requirements

+ Uses healthcare knowledge to assess the completeness and reliability of data and the validity and accuracy of results for hybrid measures.

+ Reviews, analyzes, and completes all mandated studies and medical record reviews required by CMS, NYS DOH or other regulator.

+ Works collaboratively with internal and external customers to drive Health Care Improvement while educating on measures and performance.

+ Performs detailed medical record documentation reviews for providers and reports to credentialing and appropriate internal committees.

+ Monitors and evaluates data from hybrid review results for reporting. Presents on program activities and performance internally.

+ Supports and implements initiatives to support the Risk Adjustment & HEDIS Strategic Goals and Objectives.

+ Embraces and leads change consistently demonstrating a positive can-do attitude.

+ Follows and updates as indicated, the quality of care concerns process while working in tandem with the Medical Directors, and if indicated the NYS Department of Health (DOH)

+ Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.

+ Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.

+ Regular and reliable attendance is expected and required.

+ Performs other functions as assigned by management.

Level II (in addition to Level I Accountabilities)

+ Leads outreach to internal department to drive quality improvements including but not limited to community-wide improvement initiatives.

+ Proactively researches best practice with other Health Plans to evaluate current programs, processes and complete rapid tests of change as needed.

+ Serves as a HEDIS/QARR/QRS subject matter expert on process, measures and proactively outreaches to educate both internal and external customers.

+ Reviews quality data in partnership with Quality Measurement analysts to assess measure performance.

+ Conducts medical best practice research, barrier, and root cause analysis on identified high impact quality measures to identify potential member or provider interventions.

+ Prepares and presents outcome reports on program activities and performance to internal and external stakeholders, as indicated.

+ Anticipates regulatory changes through engagement with NCQA, CMS and NYS DOH and addresses accordingly.

+ Leads process change and presents results on program activities, overall performance.

+ Collaborates with other Health Plans, government payers, consultants, providers, BCBSA and other health care entities to identify availability and use of best practices relating to HEDIS hybrid reviews, quality and performance improvement initiatives, programs, and benchmarks.

Minimum Qualifications:

NOTE: We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.

All Levels

+ Minimum five years healthcare experience required.

+ Registered Nurse with current New York State License or Certified Professional Coder certification required.

+ Bachelor’s degree in relevant field required. In lieu of degree, a minimum of five years’ progressive experience in health care ambulatory setting or health related insurance position.

+ Maintains thorough working knowledge of HEDIS/QARR/QRS measurement.

+ Maintains current and thorough understanding of federal and state regulations and advancements put forth by quality improvement organizations, including but not limited to NCQA, CMS, and NYS DOH requirements.

+ Knowledge of quality improvement methodologies.

+ Knowledge of health plan and physician offices.

+ Strong problem-solving skills. Ability to verify accuracy of data to report information correctly.

+ Excellent written and verbal communication skills. Strong interpersonal and presentation skills.

+ Ability to work with all Microsoft Office programs and databases for quality reporting.

+ Ability to work independently as well as on intra- and inter-departmental teams.

+ Demonstrates ability to interacts with all levels of management.

+ Demonstrates experience working with medical directors, providers, legal staff, NYS DOH, and federal regulators.

+ Strong healthcare background to guide problem solving related to quality concerns.

+ Research skills to assist with the information gathering required to complete quality of care cases.

Level II (in addition to Level I Qualifications)

+ Minimum 3 years of progressive HEDIS QARR QRS experience.

+ Demonstrates experience working with providers, vendors, external regulators and Certified NCQA auditors.

+ Recognized as a HEDIS/QARR/QRS subject matter expert.

+ Exhibits strong organizational and planning skills. Ability to define or identify problems and prioritizes impact or corrective action/implementation to drive execution.

+ Knowledge of regulatory programs and the health insurance industry.

+ Strong seasoned professional with highly developed critical thinking skills who can interact with internal departments, external regulators, and providers.

Physical Requirements:

+ Ability to work prolonged periods sitting at a workstation and working on a computer.

+ Ability to work while sitting and/or standing while at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time.

+ Typical office environment including fluorescent lighting.

+ Ability to work in a home office for continuous periods of time for business continuity.

+ Ability to travel across the health plan service regions as needed.

+ Ability to lift, carry, push or pull 30 pounds or less.

+ Repetitive motion required. (i.e. keystrokes and computer mouse movements)

+ Must have a valid Class D license and ability to operate a motor vehicle.

+ The ability to hear, understand and speak clearly while using a phone, with or without a headset.

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In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Compensation Range(s):

Level I: Grade N7: Minimum $23.56 - Maximum $37.70

Level II: Grade N9: Minimum $29.57 - Maximum $47.32

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position’s minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

With about 4,000 employees, 31 counties, and serving the needs of over 1.5 million members, you can imagine the gamut of skills it takes to keep our organization growing and our members flourishing. As an internal job seeker, this means growth and development in many directions, divisions, and roles.Take a look at information regarding our hiring process here. https://lifethc.sharepoint.com/sites/HumanCapitalManagement/SitePages/Talent-Acquisition-%26-Onboarding.aspx#hiring-process All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.