Position is responsible for strategically developing clinically oriented provider and community based partnerships in order to increase quality scores based on state specific quality measures. This role will be responsible for ongoing management of provider practice and community education on state specific quality measures.
The Clinical Practice Consultant will work closely with the quality director to coordinate an interdisciplinary approach to increased provider performance. This role will have a heavy focus on Pediatric HEDIS practice guidelines. You would be responsible for provider education regarding the quality improvement program that involves analysis and review of quality outcomes at the provider level, monitoring, measuring and reporting on key metrics to assist providers in meeting quality standards, state contractual requirements and pay for performance initiatives. The Clinical Practice Consultant will focus on tasks that occur in accordance with State, CMS or other requirements as applicable. This position will also be responsible for direction and guidance on provider-focused, clinical quality improvement and management programs. This role assists contracted providers with analyzing member care, trending quality compliance at the provider level, and developing action plans and programs to support provider practices in continuous quality improvement using approved clinical practice guidelines, HEDIS (Pediatric), CMS, NCQA and other tools. The position reports to the Quality Leadership of the Health Plan.
You will be assigned to provider offices in the North Miami (Dade County) area. This role requires travel to physician offices locally up to 75% of the time. Must be comfortable formally presenting to physicians and administrators, creating presentations and working with data. This is a work from home / telecommute position.
- Supports effective deployment of program at the practice level through strategic partnerships with participating practitioners and practice staff while assessing trends in quality measures and identifying opportunities for quality improvement
- Designs practice level quality transformation through targeted clinical education and approved materials related to HEDIS/State Specific quality measures for provider and staff education during field visits. Materials additionally include information from local, state, and national departments of health on key health related issues (understanding, exploring, educating and facilitating on a local level)
- Serves as subject matter expert (SME) for assigned HEDIS/State Measures, preventive health topics, leads efforts with clinical team to research and design educational materials for use in practitioner offices; serves as liaison with key vendors supporting HEDIS/State Measures; consults with vendors to design and implement initiatives to innovate and then improve HEDIS/State Measure rates
- Participates, coordinates, and/or represents the Health Plan at community based organization events, clinic days, health department meetings, and other outreach events focused on quality improvement, member health education, and disparity programs as assigned
- Identifies population-based member barriers to care and works with the QMP team to identify local level strategies to overcome barriers and close clinical gaps in care
- Reports individual member quality of care concerns or trends of concern to the Health Plan Quality Director
- Coordinates and performs onsite clinical evaluations through medical record audits to determine appropriate coding and billing practices, compliance with quality metrics, compliance with service delivery and quality standards
- Investigates gaps in clinical documentation where system variation has impact on rate calculation, provides feedback to appropriate team members where issues are verified, and monitors resolution to conclusion
- Educates providers and office staff on proper clinical documentation, coding, and billing practices, state-mandated quality metrics specifications, provider profiling and pay for performance measurement, and medical record review criteria, to drive quality improvement
- Supports continuum of member care by identifying members in need of health education and/or services (case management, etc.) and refers members to the appropriate internal departments per policy
- Documents and refers providers' non-clinical/service issues to the appropriate internal parties, to include Provider Relations and the Plan Chief Medical Officer by analyzing provider records and maintaining database
- Works with providers on standards of care, and advises providers on established clinical practice guidelines, and appropriate documentation and billing consistent with state specific measures and technical specifications