PR & Quality Measure Specialist

Tyvan LLC

About The Position

The PR & Quality Measures Specialist supports provider relations, quality improvement initiatives, and health plan performance programs within the MSO/IPA environment. The role is responsible for provider engagement, HEDIS and STAR measure support, RAF and preventive care gap closure coordination, provider education, and quality performance monitoring to improve member outcomes and operational performance. The ideal candidate has experience with Medicare Advantage, Medicaid, IPA/MSO operations, provider relations, and managed care quality programs.

Requirements

High school diploma or equivalent required.
1–2 years of experience in provider relations, healthcare quality, managed care, or IPA/MSO operations.
Experience working in one or more of the following environments: MSO, IPA, Health plan, Medical group
Managed care environment
Experience with Medicare Advantage and/or Medicaid quality programs.
Experience working with HEDIS, STAR measures, RAF, or preventive care initiatives.
Basic understanding of population health management, quality improvement programs, preventive care measures, member outreach workflows
Strong attention to detail and organizational skills.
Ability to analyze quality performance data and identify trends.
Strong Excel skills, including VLOOKUP/XLOOKUP preferred
Strong communication and relationship-building skills.
Ability to educate and engage provider offices professionally.
Ability to manage multiple projects and deadlines simultaneously.
Ability to maintain confidentiality of PHI and member information.

Nice To Haves

Associate’s degree preferred in related field
Experience in a Medicare Advantage IPA/MSO environment.
Experience with provider education and outreach programs.
Experience reviewing quality scorecards and care gap reports.
Bilingual English/Chinese/Korean/Spanish preferred.

Responsibilities

Serve as a liaison between the IPA/MSO and contracted provider offices.
Build and maintain positive working relationships with providers, clinic managers, and office staff.
Conduct provider office visits and educational meetings regarding quality initiatives and health plan requirements.
Educate provider offices on HEDIS, STAR measures, RAF capture, Annual Wellness Visits (AWV), and preventive care programs.
Monitor and track quality measure performance and care gap closure activities.
Review health plan reports, quality scorecards, RAF suspect lists, and member outreach opportunities.
Coordinate member outreach efforts related to preventive screenings, chronic disease management, and wellness services.
Assist provider offices with obtaining and submitting medical records for audits and quality initiatives.
Support chart review and documentation collection for HEDIS, RAF, and risk adjustment programs.
Monitor PCP assignment and provider participation related to quality programs.
Assist with implementation of health plan incentive and value-based care initiatives.
Support onboarding and orientation of newly contracted providers regarding quality workflows and reporting requirements.
Maintain quality tracking spreadsheets, outreach logs, and provider communication records.
Validate quality data accuracy prior to submission or reporting.
Generate operational reports related to HEDIS measures, STAR ratings, RAF opportunities, Preventive care gaps, and Provider performance metrics.
Assist with monthly quality reconciliation and performance monitoring processes.
Support audit preparation and documentation requests related to quality programs.
Analyze trends and identify opportunities for operational and quality improvement.
Communicate with health plans regarding quality initiatives, provider performance, and incentive programs.
Assist provider offices with quality measure questions and workflow optimization.
Coordinate with claims, care management, credentialing, utilization management, and operational teams.
Support provider training on payer portals, population health tools, and quality platforms.
Participate in provider meetings, quality committees, and operational improvement projects.