Quality HEDIS-STAR Nurse - JHP

Jefferson Health Plans • Philadelphia, PA

3d • Onsite

About The Position

The Clinical STARS-HEDIS Specialist provides clinical support to the Quality Management department and other areas of the organization to help close care gaps. The Specialist contributes to quality initiatives and activities, conducts provider outreach calls, and reviews medical records to support performance related to Stars, HEDIS, NCQA Accreditation, CAHPS, and Patient-Centered Medical Home (PCMH).

The position includes reviewing clinical records and assessments, identifying potential gaps in care and adherence issues, supporting HEDIS-season chart reviews, and working with internal departments to address quality concerns. The Specialist documents work in required systems and follows established protocols for telephone and information systems.

Requirements

• Bachelor’s degree in Nursing.
• At least 3 years of experience in managed care, clinical case management, or quality review.
• Proficiency with Microsoft Office, SharePoint, and Teams.
• Knowledge of clinical case management and medical terminology.
• Ability to read and interpret standards to perform job functions.
• Exceptional presentation, oral and written communication, interpersonal, problem-solving, multitasking, and time-management skills.
• Exceptional customer service skills.
• Ability to work independently and as part of a team.
• Active Registered Nurse license in Pennsylvania.
• Pennsylvania driver’s license.

Nice To Haves

• Experience with various electronic medical records (EMRs).
• Ability to organize and manage multiple priorities.

Responsibilities

• Conduct provider outreach calls to complete clinical and quality assessments related to HEDIS and Stars, including pain and functional assessments.
• Conduct quality medical record reviews to assess continuity and effectiveness of care management and report potential gaps or adherence issues to primary care providers against clinical, HEDIS, Stars, credentialing and re-credentialing, and other regulatory objectives.
• Assist the Quality Management team with medical chart reviews or overreads during the HEDIS season.
• Identify quality-related issues and recommend potential solutions.
• Identify and share best practices, contribute significantly to process improvement initiatives, and actively support those initiatives.
• Collaborate with internal departments, including HEDIS, Care Management, UM, enrollment, member services, and Complaints and Grievances, to resolve potential quality issues and concerns.
• Document appropriately in the Care Management system, Access, Excel files, and other areas as required by departmental requirements.
• Operate CIC and telephone systems effectively and efficiently, following established security, transfer, and information-exchange protocols.
• Perform other duties as assigned.

Benefits

• Medical insurance, including prescription coverage.
• Supplemental insurance.
• Dental insurance.
• Vision insurance.
• Life and AD&D insurance.
• Short- and long-term disability insurance.
• Flexible spending accounts.
• Retirement plans.
• Tuition assistance.
• Voluntary benefits, including access to group insurance rates and discounts.
• Tuition discounts at Thomas Jefferson University after one year of full-time service or two years of part-time service.
• Medical insurance, including prescription coverage, is available to all colleagues, including those working less than part-time.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level