Quality Care Coordinator

Menasha•Menasha, WI

19d•Hybrid

About The Position

The Quality Care Coordinator develops, implements and provides ongoing monitoring of intervention plans and quality gap closure. The overall goal of this role is to reduce medical costs and improve quality ratings. The Quality Care coordinator achieves this goal through member and/or provider engagement, internal quality process improvement work, and coordination of overall clinical intervention strategies. The Quality Care Coordinator conducts HEDIS and year-round medical record reviews and is responsible for ensuring that Network Health meets all OCI, CMS and NCQA quality requirements. This role will have varying areas of focus depending on business need, this coordinator could be the SME for quality, condition management, clinical integration or the clinical support for the appeals and grievance process. Location: Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at your home office (reliable internet is required), at our office in Brookfield or Menasha, or a combination of both with our hybrid workplace model. Hours: 1.0 FTE, 40 hours per week, 7:30am - 5pm Monday through Friday Check out our 2024 Community Report to learn a little more about the difference our employees make in the communities we live and work in. As an employee, you will have the opportunity to work hard and have fun while getting paid to volunteer in your local neighborhood. You too, can be part of the team and making a difference. Apply to this position to learn more about our team.

Requirements

Bachelors degree in related field required, Bachelors degree in Nursing preferred
4 years clinical RN experience preferred
Experience in basic data analysis, quality improvement, or HEDIS medical record review, preventive care, or health plan experience preferred
WI Registered Nurse (RN) licensure preferred

Responsibilities

Provide direct outreach to members and/or providers in order to close quality gaps and maintain or exceed expected population health outcomes per HEDIS, Stars and NCQA
Create written materials for members, physicians, and other customers in formats such as newsletters, brochures, self-care materials, educational handouts, letters and telephone scripts
Responsible for development and coordination of member centric programs in alignment with industry and regulatory standards
Evaluate utilization patterns, medical records and other metrics to monitor quality and efficiency results
Provide clinical support for the appeals and grievance department and quality of care complaint process, preparing cases for medical director review when needed
Identify opportunities for improvement and implements clinical interventions
Prepare and/or deliver presentations for Quality Management committee, clinic or provider education, and system-wide committees as needed
Coordinate, monitor, and document quality interventions and care management programs with goal of effectiveness that promotes value added care and service
Collaborate closely with secondary providers (Breathe at Ease, Home Telemetry, Diabetes programs) to coordinate services for members
Function as a liaison when needed for family, member and provider to communicate any current of potential issues
Prepare reports as necessary
Develop review and revise department policies and procedures including preventive services requirements
Provide recommendations for preventive services medicine and evidence based clinical guidelines, seek approval and monitor for updates or relevant changes as assigned
Research, submit, and evaluate quality improvement projects regulated by CMS as assigned
Implement systems of care that facilitate close monitoring of members to promote early intervention
Assist with updating and maintaining Clinical Integration (CI) manual and documentation related to CI including reports
Assist with meeting directly with CI providers (frontline staff) to answer questions and come up with action plans related to CI contract, other related Clinical integration meetings that require clinical representative
Manage CI provider quality improvement fund including quarterly updates, follow-up, and report out on results
Assist with CI PCP attribution process and supplemental data including troubleshooting electronic medical record access.
Assist with CI provider project management.
Other duties as assigned.