QCI Specialist I
About The Position
This role is integral in supporting our mission to advance quality care across our network, particularly within the Southern California IPAs. Reporting to the Supervisor of Quality Care Improvement, the Specialist will serve as a key liaison to lead and coordinate initiatives that drive performance in HEDIS, CMS Star Ratings (Part C & D), and overall health plan quality metrics. What You'll Do Serve as a quality performance resource to assigned health plan partners, provider groups, clinics, and MSOs, providing and presenting HEDIS performance scorecards monthly Conduct targeted member outreach to support strategic initiatives and campaigns aimed at improving performance metrics for health plans and provider offices Collaborate with assigned health plans and/or provider offices to improve documentation, coding accuracy, and care gap closure Collect, review, validate and attest medical records to ensure accuracy and completeness for reporting purposes Analyze provider performance data, identify trends, and deliver targeted education to drive improvements Support monthly supplemental data submission, file preparation, and verification of compliant coding Work with internal teams and vendors to validate, reconcile, and audit HEDIS records to ensure completeness and accuracy Prepare reports, scorecards, and presentations for leadership review Obtain data needed for Primary Source Verification audits from health plans and vendors and ensure timely submission Provide in-service training to primary care providers and office staff on quality metrics, incentive programs, and documentation integrity Act as a subject matter expert on CMS, HEDIS, NCQA, HIPAA, and health plan standards Lead end-to-end quality improvement projects on HEDIS, CMS Stars, and regulatory compliance Conduct comprehensive training for PCPs and specialists on: Quality Measures HEDIS and CMS Star Ratings Performance-Based Incentive Programs Data Accuracy and Documentation Standards Other duties as assigned.
Requirements
- Bachelor’s degree or equivalent experience
- 3–5 years of experience in healthcare, ideally in IPA/MSO/Health Plan environments
- Minimum of 1 year of HEDIS-related experience
- Independent transportation and ability to travel up to 25% as needed
- Strong knowledge of managed care and quality program standards
- Excellent analytical, communication, and presentation skills
- Demonstrates initiative, creativity, and a collaborative mindset
Nice To Haves
- Fluent in Spanish and/or Chinese (Mandarin/Cantonese)
- Familiar with practice management and financial operations
- Are adaptable, self-motivated, and eager to grow within a mission-driven organization
- Highly organized, detail-oriented, and capable of managing multiple priorities in a dynamic environment
- Experienced in outpatient clinical settings
Responsibilities
- Serve as a quality performance resource to assigned health plan partners, provider groups, clinics, and MSOs, providing and presenting HEDIS performance scorecards monthly
- Conduct targeted member outreach to support strategic initiatives and campaigns aimed at improving performance metrics for health plans and provider offices
- Collaborate with assigned health plans and/or provider offices to improve documentation, coding accuracy, and care gap closure
- Collect, review, validate and attest medical records to ensure accuracy and completeness for reporting purposes
- Analyze provider performance data, identify trends, and deliver targeted education to drive improvements
- Support monthly supplemental data submission, file preparation, and verification of compliant coding
- Work with internal teams and vendors to validate, reconcile, and audit HEDIS records to ensure completeness and accuracy
- Prepare reports, scorecards, and presentations for leadership review
- Obtain data needed for Primary Source Verification audits from health plans and vendors and ensure timely submission
- Provide in-service training to primary care providers and office staff on quality metrics, incentive programs, and documentation integrity
- Act as a subject matter expert on CMS, HEDIS, NCQA, HIPAA, and health plan standards
- Lead end-to-end quality improvement projects on HEDIS, CMS Stars, and regulatory compliance
- Conduct comprehensive training for PCPs and specialists on: Quality Measures HEDIS and CMS Star Ratings Performance-Based Incentive Programs Data Accuracy and Documentation Standards
- Other duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
