Quality HEDIS-STAR Nurse - JHP

Thomas Jefferson University • Philadelphia, PA

2d • Onsite

About The Position

The Clinical STARS-HEDIS Specialist provides clinical support to the Quality Management department and other organizational areas to assist with care gap closure. The role contributes to quality initiatives and activities, including provider outreach and medical record reviews, to support the organization’s performance in Stars, HEDIS, NCQA Accreditation, CAHPS, and Patient-Centered Medical Home (PCMH). The position also collaborates with internal teams to resolve potential quality issues, documents work in designated systems, and performs other duties as assigned.

Requirements

• Bachelor’s degree in Nursing.
• Three 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.
• Licensed Registered Nurse in Pennsylvania.
• Pennsylvania driver’s license.
• Ability to lift and carry 25 pounds; frequent sitting and standing; frequent keyboard use. Patient-care providers may also need to kneel, bend, squat, and perform CPR.

Nice To Haves

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

Responsibilities

• Conduct provider outreach calls and complete clinical and quality assessments related to HEDIS and Stars, including pain and functional assessments.
• Review medical records to assess continuity and effectiveness of care management and report potential gaps or adherence issues to primary care providers in relation to clinical, HEDIS, Stars, credentialing and re-credentialing, and other regulatory objectives.
• Support 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 to process improvement initiatives, and support those initiatives.
• Collaborate with internal departments, including HEDIS, Care Management, Utilization Management, enrollment, member services, and Complaints and Grievances, to help resolve potential quality issues and concerns.
• Document work in the Care Management system, Access, Excel files, and other required areas according to departmental requirements.
• Operate CIC and telephone systems according to established protocols for security, transfer, and information exchange.
• 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
• 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 per diem colleagues, adjunct faculty, and Jeff Temps.

What This Job Offers

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