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This position is responsible for ongoing HEDIS collection and improvement activities at the health plan and reports to the Quality Management Leader.
This position will be covering Corpus Christi, TX and surrounding areas.
This position will be work at home and out in the field 75 percent of the time.
- Coordinates and performs onsite medical record reviews at provider offices to determine appropriate coding and billing practices, compliance with quality metrics, compliance with service delivery and quality standards, and where assigned investigation of quality of care and member complaints relative to quality of care and service. Support continuum of member care by identifying members in need of health education, case management, etc.
- Educates providers and office staff on proper coding and billing practices, HEDIS and state-mandated quality metrics specifications, provider profiling and pay for performance measurement, and medical record review criteria. Solicit identification of barriers the office faces in providing care to members
- Supports the HEDIS medical record chase to support optimum HEDIS and quality metric reporting
- Supports quality improvement program studies requesting records from providers, maintaining databases, and researching to identify members' provider encounter history
- Participates in and represents plan at community, health department, collaborative and other organizational meetings focusing on quality improvement, member education, and disparity programs, as assigned
- Performs annual medical record evaluation, follow-up education, practitioner intervention, measurement (QI 13) as required
- Enter documentation of findings in identified database
- Generally works independently, under the supervision of the Quality Management leader
- Participates in or coordinates with other department projects as needed