Government Programs Clinical Quality & HEDIS Specialist

Arkansas Blue Cross Blue Shield

1d•$57,800 - $75,100•Remote

About The Position

This position has split responsibility for HEDIS abstraction and quality work, as well as member and provider engagement to improve overall quality performance. The specialist conducts telephonic care coordination, identifies opportunities for intervention—including preventive care screenings, disease-state management, appropriate medication use, and other healthcare needs—and helps members access appropriate health-related services. The role works closely with members, pharmacies, and physicians to support comprehensive, coordinated care and improve clinical government program quality and performance. It also requires extensive knowledge of HEDIS measures and medical record abstraction to close care gaps and gather additional data. The position is work-from-home within Arkansas, Washington, Oregon, Utah, Idaho, North Dakota, or Minnesota. Preference is given to current employees and candidates residing in Arkansas, Utah, Idaho, and North Dakota. The role is classified as a general office worker, sedentary, with campus travel, and requires travel within the designated service area as necessary.

Requirements

Bachelor’s degree in Health Science, Public Health, Psychology, Social Work, Health Administration, or another healthcare-related field; alternatively, five years of related experience may meet the education requirement.
An associate degree in one of the specified or related fields may be used with an additional two years of related experience to meet the education requirement.
Valid driver’s license.
Pass the Inter-Rater Reliability (IRR) test within 90 days of hire and/or assignment. A score of 95% is required; failure to pass after training and a second attempt may result in disciplinary action under the Performance Standards Manual.
At least three years of work experience in direct patient care, social work, quality improvement, health coaching, clinical or healthcare-service quality improvement, or health data analytics. Managed care experience and experience involving Stars/HEDIS or medical record review audit are preferred.
At least one year of Medicare Advantage experience.
Experience working directly with patients.
Knowledge of and ability to work within a complex healthcare system, advocating for member needs while balancing organizational needs.
Ability to understand the needs of culturally diverse populations and evaluate literacy and literacy needs.
Excellent written and verbal communication skills when interacting internally and externally.
Strong independent and critical-thinking skills to understand individual and operational problems and identify appropriate solutions.
Strong interpersonal, presentation, problem-solving, and organizational skills.
Proficiency in Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook.
Ability to travel within the designated service area as necessary.
Ability to protect confidential healthcare information and comply with applicable laws, policies, rules, and regulations.
Ability to work independently in Microsoft Office applications with little to no training.
Ability to demonstrate and express empathy and compassion verbally and by telephone.
Ability to assess needs and design, develop, and implement goal-oriented care plans.
Ability to work in a fast-paced environment with changing priorities.
Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions.

Nice To Haves

Active licensure or certification as a Registered Nurse (RN), Licensed Practical Nurse (LPN), Licensed Baccalaureate Social Worker (LBSW), or Certified Pharmacy Technician (CPhT).
Certified Professional Coder (CPC) certification.
Experience as a health navigator, patient navigator, patient advocate, care advocate, or health coach.
Experience working closely with and/or advocating for culturally diverse individuals or individuals of lower socioeconomic status.
Strong understanding of HEDIS measures and technical specifications.
Skills and experience in medical record abstraction, claims coding, education, and training.
Bilingual ability.
Residence in Arkansas, Utah, Idaho, or North Dakota; preference is also given to current employees.

Responsibilities

Assist in creating member and practitioner educational materials related to quality management activities and program information.
Assist in implementing new or ongoing quality improvement initiatives.
Build relationships and serve as a liaison and advocate among members, network providers, city and county health departments, and community service organizations.
Retrieve, abstract, and overread clinical medical record documentation for HEDIS audit activities and quality-gap provider initiatives, ensuring accuracy and compliance with CMS guidelines.
Develop work and progress plans for members based on interactions and insights gained.
Help members schedule needed care appointments and navigate the healthcare delivery system.
Identify and triage members to appropriate healthcare resources, care coordination, assistance with medical care questions, and resolution of barriers to effective use of healthcare resources.
Measure, analyze, and report HEDIS quality initiative results; collaborate on tools to capture and report relevant information and identify member and provider quality-gap trends.
Perform other activities and projects as directed by the Clinical Quality & HEDIS Leadership team.
Conduct telephonic outreach and health coaching with members and families regarding medication adherence, preventive care reminders and reinforcement, and other Stars measures to improve member experience and remove barriers to care.
Assess and evaluate members' service needs and guide them toward optimal wellness and care using motivational interviewing techniques and advocacy.
Support provider outreach initiatives, including sending gap reports and requesting medical records.
Work with Stars Member Outreach Specialists, Stars Improvement Nurses, and health plan staff to monitor gap closures and improvement activities.