The purpose of this position is to support the health network’s quality and performance goals, with a focus on achieving a 5-star rating for performance in value-based care contracts and our accountable care organization (ACO). This includes conducting outbound calls to members to previsit plan and close HEDIS gaps in care, discussing the importance of early detection and disease prevention. Will be contacting medical offices to coordinate appointments and facilitate necessary services to support patient health and mitigate any future issues. The role will also require ongoing communication and collaboration with the internal and external healthcare providers, office staff, and the payer partner liaison team.
Responsibilities
Core Responsibilities:
Data Management & Reporting: Analyze HEDIS performance in Epic dashboards and payer reports, identifying trends and presenting findings to leadership.Ensure data accuracy and completeness through regular audits and reconciliations.
Quality Improvement Initiatives: Develop and implement strategies to close care gaps, including provider education, member outreach, and process enhancements. Monitor the effectiveness of these initiatives and adjust as necessary.
Medical Record Review & Abstraction: Conduct chart reviews to extract relevant data for HEDIS measures, ensuring compliance with NCQA guidelines. Collaborate with clinical staff to address documentation deficiencies.
Provider & Member Engagement: Assist providers in understanding and meeting HEDIS requirements through communication and support. Engage with members to encourage participation in preventive care services.
Regulatory Compliance: Stay informed about changes in HEDIS specifications, NCQA standards, and CMS regulations. Ensure all activities align with these requirements to maintain accreditation and optimize quality scores.
Daily/Monthly/Quarterly work responsibilities:
Responsible for driving improved quality performance within an assigned payer contract(s) and capturing the highest realistic revenue within impactable measures.
Organize and maintain a plan of action to improve HEDIS performance.
Request and evaluate reports for member compliance and improvement opportunities for each HEDIS measure.
Work with providers and internal departments on rate investigation and validation activities which includes maintaining all evidence, documentation and changes.
Develop collaborative relationships with payer representatives and use best practice techniques for patient outreach and HEDIS compliance.
Work in partnership with Payer Relations Enrollment team to support best attribution management practices. Will follow up and communicate regularly with TCHMA administration, billing department, and office managers.
In partnership with Payer Relations Enrollment team, will ensure timely and accurate submissions of provider disenrollment status.
Conduct outbound calls to members to encourage quality measure adherence and close HEDIS gaps in care.
Educate members on the importance of quality healthcare services including disease prevention and annual wellness visits.
Connect patients with payer patient benefits inclusive of paid incentives.
Contact provider offices to coordinate care
Contact internal and external facilities to verify service completion and retrieve necessary medical documentation to confirm quality compliance within the required performance year.
Communicate and collaborate regularly with internal and external healthcare teams inclusive of providers, office staff, nurse care manager, social workers, behavioral health counselors, as well as with the assigned payer liaison team.
Refer patient for support services within Population Health should patient verbalize needs during conversation (i.e. nurse care management, social work, behavioral health counseling, pharmacy).
Assist with HEDIS data submission, including organizing and interpreting adherence data to help support HEDIS compliance.
Document all member and provider interactions accurately in designated systems and escalate issues as needed.
Proactively make suggestions for improvements in contract specific metrics or workflow.
Ensure data correction is completed by the end of the measurement year
Maintain accurate records of outreach activities and outcomes
Monitor outreach outcomes and support continuous improvement in adherence initiatives.
Actively participates in Joint Operations Committee with payer.
Supplemental data submission and tracking.
Use multiple systems (Epic CC Dashboard, payer portal, spreadsheets) for prioritizing work.
Meet expected productivity goals
Maintain confidentiality and comply with HIPAA and organizational policies.
Other Duties as assigned
Qualifications
EDUCATION: High school graduate required. Relevant Associates degree and/or equivalent health care experience preferred; Bachelors degree a plus.
YEARS OF EXPERIENCE:
Minimum of 2+ years of experience in a healthcare or payer setting, with a focus on patient outreach, customer service or care coordination is required. Experience with member or patient outreach, customer service, or care coordination strongly preferred.
REQUIRED SKILLS AND KNOWLEDGE:
Knowledge of HEDIS measures, Commercial, Medicare, Medicaid quality programs and quality measure adherence is preferred.
Previous patient care experience is a plus.
Excellent verbal communication and interpersonal skills, with the ability to educate, motivate, and problem-solve over the phone.
Comfortable making high-volume outbound calls to members, providers, and payers.
Proficient in Microsoft Office, specifically Excel and experienced with healthcare data systems or EMRs. Epic experience is a plus.
Basic analytical skills, including experience working with spreadsheets (Excel or similar), and the ability to interpret and organize data effectively.
Strong attention to detail, time management, and the ability to work both independently and as part of a cross-functional team.
Commitment to maintaining confidentiality and complying with HIPAA and organizational standards.