Associate Quality Practice Advisor

Centene Management Company•Orlando, FL

4d•Hybrid

About The Position

Supports the Quality Improvement team by partnering with provider offices in the Central Florida / greater Orlando area. Focuses on HEDIS quality measures, provider performance reports, quality score improvement, provider education and engagement, and workflow improvement recommendations. The role establishes and fosters a healthy working relationship between community physician and small provider practices and WellCare. It educates providers and supports provider practice sites in regards to the National Committee for Quality Assurance (NCQA) HEDIS measures, providing education for HEDIS measures, appropriate medical record documentation and appropriate coding. Assists in resolving deficiencies impacting plan compliance to meet State and Federal standards for HEDIS. Under general guidance from Senior Quality Practice Advisors and management, educates community physician and small provider practices in appropriate HEDIS measures, medical record documentation guidelines and HEDIS ICD-9/10 CPT coding in accordance with NCQA requirements. Collects, summarizes and trends provider performance data to identify and strategize opportunities for provider improvement. Collaborates with Provider Relations to improve provider performance in areas of Quality, Risk Adjustment and Operations (claims and encounters). Assists in delivering provider specific metrics and coaches providers on gap closing opportunities. Assists in identifying specific practice needs where WellCare can provide support. Partners with physicians/physician staff to find ways to encourage member clinical participation in wellness and education. Provides resources and educational opportunities to provider and staff. Captures concerns and issues in action plans as agreed upon with provider. Documents action plans and details of visits and outcomes. Reports critical incidents and information regarding quality of care issues. Communicates with external data sources as needed to gather data necessary to measure identified outcomes. Provides communication such as newsletter articles, member education, outreach interventions and provider education. Supports quality improvement HEDIS and program studies as needed, requesting records from providers, maintaining databases, and researching to identify members' provider encounter history. Ensures that documentation produced and/or processed complies with state regulations and/or accrediting body requirements. Ensures assigned contract/regulatory report content is accurate and that submission adheres to deadline. Enters documentation of findings in identified databases and ensures accuracy in medical records for data collection, DE and reporting. Performs other duties as assigned. Complies with all policies and standards.

Requirements

A Bachelor's Degree in Healthcare, Public Health, Nursing, Psychology, Health Administration, Social Work or related field or equivalent work experience within a managed care environment related to HEDIS record review, quality improvement, medical coding or transferable skill sets that demonstrates the ability to perform the role.
1+ year of experience in related HEDIS medical record review or quality improvement with experience in data and chart reviews to provide consultation and education to providers and provider staff OR 2 years medical coding or other transferable experience and skill set combination that demonstrates the ability to learn and perform the level of the position.
Candidate must live in the Central Florida / greater Orlando area (Orlando, Kissimmee, Winter Garden, Winter Park, Surrounding Central Florida communities).
Candidate must be close enough to travel to provider offices.

Nice To Haves

A Master's Degree in Healthcare, Public Health, Nursing, Psychology, Health Administration, Social Work or related field.
A license in one of the following is preferred: Certified Coding Specialist (CCS), Licensed Practical Nurse (LPN), Licensed Master Social Work (LMSW), Licensed Vocational Nurse (LVN), Licensed Mental Health Counselor (LMHC), Licensed Marital and Family Therapist (LMFT), Licensed Certified Social Worker (LCSW), Licensed Registered Nurse (RN), Acute Care Nurse Practitioner (APRN) (ACNP-BC), Other Foreign trained physician/MD, Health Care Quality and Management (HCQM), Certified Healthcare Professional (CHP), Certified Professional in Healthcare Quality (CPHQ).

Responsibilities

Establishes and fosters a healthy working relationship between community physician and small provider practices and WellCare.
Educates providers and supports provider practice sites in regards to the National Committee for Quality Assurance (NCQA) HEDIS measures.
Provides education for HEDIS measures, appropriate medical record documentation and appropriate coding.
Assists in resolving deficiencies impacting plan compliance to meet State and Federal standards for HEDIS.
Educates community physician and small provider practices in appropriate HEDIS measures, medical record documentation guidelines and HEDIS ICD-9/10 CPT coding in accordance with NCQA requirements.
Collects, summarizes and trends provider performance data to identify and strategize opportunities for provider improvement.
Collaborates with Provider Relations to improve provider performance in areas of Quality, Risk Adjustment and Operations (claims and encounters).
Assists in delivering provider specific metrics and coaches providers on gap closing opportunities.
Assists in identifying specific practice needs where WellCare can provide support.
Partners with physicians/physician staff to find ways to encourage member clinical participation in wellness and education.
Provides resources and educational opportunities to provider and staff.
Captures concerns and issues in action plans as agreed upon with provider.
Documents action plans and details of visits and outcomes.
Reports critical incidents and information regarding quality of care issues.
Communicates with external data sources as needed to gather data necessary to measure identified outcomes.
Provides communication such as newsletter articles, member education, outreach interventions and provider education.
Supports quality improvement HEDIS and program studies as needed, requesting records from providers, maintaining databases, and researching to identify members' provider encounter history.
Ensures that documentation produced and/or processed complies with state regulations and/or accrediting body requirements.
Ensures assigned contract/regulatory report content is accurate and that submission adheres to deadline.
Enters documentation of findings in identified databases and ensures accuracy in medical records for data collection, DE and reporting.
Performs other duties as assigned.
Complies with all policies and standards.