HEDIS Specialist

Borinquen Health Care Center•Miami, FL

About The Position

Borinquen Medical Centers is seeking a full-time HEDIS Specialist in Miami, Florida. The position communicates provider participation information to internal and external customers through established processes to support appropriate patient scheduling, reimbursement for services, and achievement of HEDIS and P4P measures. The Specialist verifies and updates patient registration information, including insurance, demographic, and patient data, and works with departments to resolve registration issues. As a member of the Care team, the Specialist supports Quality Improvement, policies and procedures, and care-team activities. The role helps patients comply with disease-management goals, documents pre- and post-call activity and care in the E.H.R. to support continuity of care, and provides daily, weekly, and monthly reports to the QI Manager based on E.H.R. data and HEDIS activities. The Specialist also tracks patient visits and supports access to care in accordance with standard care guidelines.

Requirements

Associate college degree.
Well organized and bilingual in Spanish and/or Creole.
Computer literacy and proficiency with Microsoft Office, including Outlook, Word, and Excel.
Ability to interact effectively with patients, administration, faculty, and staff.
Ability to handle information with a high level of confidentiality.
Considerable knowledge of standard concepts, practices, and procedures within a field.
At least one year of customer service experience.
Strong interpersonal skills.

Nice To Haves

Bachelor’s degree.
Clinical background experience, such as LPN or MA, with case management experience.

Responsibilities

Coordinate and complete HEDIS quality projects in alignment with BMC strategy, commitments, and goals.
Obtain and validate patient rosters from participating health insurance plans.
Contact registered patients to schedule appointments, evaluate Quality Management Tab, Avhana, and HEDIS information, and determine appointment reasons.
Schedule appointments and help ensure compliance with quality measures and completion of care gaps.
Track quality measures and Medicare population utilization; sell BHCC services when needed.
Assist with Chronic Care Management (CCM), shared medical appointments, and group visits.
Track hospital discharges and bring patients in for continuity of care.
Identify resources to address gaps in existing or quality projects and perform analyses that support documentation.
Periodically audit records and conduct internal and external chart audits when requested to confirm compliance with HEDIS and NCQA standards.
Ensure scheduled and tracked patients fulfill care gaps and document barriers that prevent them from doing so.
Verify and update patient registration information, including insurance, demographic, and patient data, when scheduling appointments.
Maintain internal rosters to reduce inadvertent leakage caused by incorrect listings.
Retrieve, communicate, and present data and information verbally and in writing.
Provide accurate and timely paneling information to Health Plans.
Coordinate with the Quality Manager weekly.
Perform and track call campaigns for non-compliant patients to increase access to care.
Increase and track access to care for patients who have not attended a primary care provider visit in the last six months.
Inform patients about covered benefits and services offered by their primary health plan.
Support QI, policies and procedures, and the Care team; document pre- and post-call activity and care in the E.H.R.
Provide daily, weekly, and monthly reports to the QI Manager.