Quality and Risk Advisor (Bilingual Vietnamese or Chinese)

Clever Care Health Plan•Huntington Beach, CA

4d•$72,800 - $80,000•Hybrid

About The Position

This position operates on a hybrid work schedule, requiring 3 days onsite at the Huntington Beach office. The Quality/Risk Advisor is responsible for establishing and maintaining positive working relationships with Management Service Organizations (MSOs), Independent Physician Associations (IPAs), and Provider Partners. This involves managing and providing ongoing education and support related to Managed Care performance expectations, including HEDIS/Stars, CAHPS, Risk Adjustment, and other Quality/Risk related Key Performance Indicators (KPIs) and State/Federal regulatory requirements. The Advisor will ensure providers have the necessary tools, resources, and support to meet Clever Care’s members' needs and performance expectations. The role involves collaboration with internal cross-functional teams, external provider networks, and vendors on Quality Initiatives, Action Planning, Data Reconciliation, Medical Record Reviews, and Education/Trainings.

Requirements

Bachelors Degree or 4+ years of work-related experience in a similar position required.
2 years of managed care experience required.
2 years of HEDIS/Risk training or education experience preferred.
Managed Care Experience is a plus.
Effectively manage and foster positive working relationships.
Leads by example and models the way.
Highly motivated to deliver results.
Microsoft Suite including expertise in Excel, Powerpoint, Access etc.
Effective communications skills.
Knowledge of HEDIS/Risk regulatory requirements.
Experience with HEDIS Hybrid Project.
Knowledgeable in HEDIS/Risk documentation and coding guidelines.
Expertise in data reconciliation, root cause analysis, and barrier analysis.
Accountable and driven to exceed expectations.

Nice To Haves

Bilingual Vietnamese or Chinese

Responsibilities

Establish and maintain positive working relationships with MSO/IPA and Providers.
Quality/Risk Performance Oversight, including meetings, presentations, and development of tools, resources, and support to ensure MSO/IPAs and providers meet key performance indicators.
Educate MSO/IPAs and providers on NCQA HEDIS measures and regulatory requirements, risk adjustment, coding best practices, and CAHPS.
Collect, summarize, and trend provider data for HEDIS/Risk to develop performance improvement plans.
Support HEDIS chart collections, abstractions, and summary of findings for provider education.
Participate in external and internal cross-functional workgroups to establish and monitor QI/Risk KPIs, Quality Initiatives, Barrier Analysis, and Annual Workplan Reviews and Evaluations.
Actively participate in Member Experience Initiatives, including Member Experience Workgroup, Member Advisory Committee, and Member Appreciation Events.
Work closely with Provider Relations and Community Center representatives on Quality/Risk and Member Experience related tasks.
Partner with the Pharmacy team on MSO/IPA and Provider Medication Adherence Performance Initiatives/Strategies.
May be required to support Member/Provider outreach as needed for Quality/Risk related activities.
Lead and conduct MSO/IPA and Provider Meetings in-person and/or via team meetings.
Meet with assigned MSO/IPA and Providers at a minimum monthly for performance management, oversight, and QI strategies.
Create agendas, PowerPoint presentations, and effectively drive meetings, keeping providers/IPAs engaged and accountable for results.
Timely distribution of meeting notes and oversight of action items through completion.