Clinical Quality Manager

HealthFirst•New York, NY

About The Position

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

Requirements

Associate’s degree from an accredited institution
Ability to travel around the NYC metro area

Nice To Haves

Bachelor’s Degree from an accredited institution
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

Responsibilities

Improve the quality of care with a focus on HEDIS, QARR and Medicare Advantage Star measures
Interact with hospitals, providers, and members to improve quality of care, monitor progress, and recommend changes
Review billing codes, medical records, and claims submission process to ensure accuracy
Attend and facilitate any initiative meetings (studies, partnerships) that involve targeted providers and/or measures.
Complete 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.
Collaborate with other departments to maximize member outreach for preventive services and chronic disease management.
Assist in writing member and/or provider articles in relation to HEDIS, QARR, Medicare Advantage and/or health promotions for HF newsletter.
Support regulatory affairs, as deemed necessary by management.
Document all relevant interactions in appropriate systems
Additional duties as assigned