Quality & Risk Adjustment Specialist

Avera•Sioux Falls, SD

12d•$21 - $27

About The Position

Responsible for activities focused around Risk Adjustment (RA) initiatives and Healthcare Effectiveness Data Information Sets (HEDIS). The Quality and Risk Adjustment Specialist will work closely with the Director of Quality and Risk Services, Manager of Risk Adjustment, Manager of Quality, Quality Coordinator – HEDIS, coder(s), claims staff, and primary care & specialty care providers to ensure that proper clinical documentation. The QRA Specialist will be responsible for ensuring that medical records for identified members are retrieved, reviewed and documented appropriately for all Quality and RA initiatives.

Requirements

The individual must be able to work the hours specified.
To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds.
These requirements and those listed above are representative of the knowledge, skills, and abilities required to perform the essential job functions.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions, as long as the accommodations do not cause undue hardship to the employer.
4-6 years professional experience in insurance or managed care industry.

Nice To Haves

Bachelor's or combination of education and experience

Responsibilities

Understand the rationale behind Risk Adjustment
Work with physicians, clinic staff, coding, and other Health Plans staff to resolve coding or work process issues in regards to RA.
Supports clinic RA visits & audits.
Responsible for ensuring appropriate parties complete designated RA tasks
General understanding of Hierarchical Condition Coding
Oversight of External Data Gathering Environment (EDGE) submission process.
Observes, investigates, and reports any trending issues which may cause quality or RA gaps.
Expand job related knowledge through participation in approved continuing education and in-services, including offsite meetings and webinars, in regards to Risk Adjustment and HEDIS.
Supports annual RADV (Risk Adjustment Data Validation) audit with multiple Health Plans departments.
Participates in HEDIS abstraction efforts in collaboration with Quality Coordinator – HEDIS.
Supports member and provider outreach initiatives to close quality and RA gaps.
Identifies opportunities for synergies related to medical record review and manages the medical record request process for Quality and RA.