Clinical Quality Specialist (52644)

GLOBALHEALTH HOLDINGS LLC•Oklahoma City, OK

3d•Remote

About The Position

GlobalHealth is a fast-growing Medicare Advantage HMO health insurer seeking a Clinical Quality Specialist. This role is crucial for improving member care through quality initiatives. The specialist will manage care gaps, conduct data entry, track referrals, and perform outreach to members and providers. The company values accountability, drive, innovation, and continuous learning, aiming to be an employer of choice by providing high-touch, high-value, and personalized services to its members.

Requirements

High School diploma or equivalent required.
Current Certified/Registered Medical Assistant in State of Oklahoma or six months of experience with a health plan or within a quality department or clinical setting required.
Valid state Drivers License, reliable personal vehicle and proof of personal vehicle liability insurance required.
Computer literate and familiar with Microsoft applications (Word, Excel).
Basic electronic health record knowledge and ability to quickly learn new software.
Detailed knowledge of quality performance measures and clinical health care.
Strong organizational and time management skills.
Strong verbal and written communication skills.
Certified/Registered Medical Assistant in State of Oklahoma or will consider 3 years of experience with a health plan, Quality Department or clinical setting.
Ability to communicate and manage complex working relationships.
Strong organizational, verbal, time management, and telephone skills.
Must have valid Oklahoma drivers license and able to drive a car.

Nice To Haves

Six months of experience with a health plan or within a quality department or clinical setting.

Responsibilities

Supports and maintains outreach initiatives with members and providers.
Effectively educates providers on quality metric guidelines to enhance patient compliance.
Performs accurate data entry in HEDIS software system and outreach tracking system.
Reviews and maintains medical records to identify, confirm, and/or document referrals, results, and appropriate medical coding.
Conducts record audits at remote provider offices.
Maintains detailed technical understanding of HEDIS, CAHPS, HOS, and Meaningful Use measures set by CMS performance standards.
Must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy.
Performs other duties as assigned.
Support and maintain outreach initiatives and other quality improvement strategies.
Answers questions and provides clear instructions to enhance patient compliance and support quality metrics.
Maintains and reviews medical records for purposes of identifying, confirming, and/or documenting referrals, results and appropriate medical coding.
Scans and indexes documents to patient charts as needed.
Adhere to company and department policies and procedures.
Maintains appropriate certification and/or license as required for this position.