This position is responsible for ongoing HEDIS collection and improvement activities at the health plan and reports to the Quality Manager.
Coordinates and performs offsite medical record reviews 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.
Provide clinical expertise to Medical groups and key high volume providers, which will include but not limited to, HEDIS/STAR measures education, gap listing engagement, workflow process improvements, improved documentation practices.
Supports the HEDIS medical record chase to support optimum HEDIS, STAR ratings and other quality metric reporting.
Work collaboratively with Data Analyst to develop stronger and more real-time EMR integration efforts
Assist in the development of new HEDIS/STARS interventions and corrective action plans for measures that fall below goals
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, and practitioner intervention Enter documentation of findings, in identified database
Develop and maintain the HEDIS training manual.
Participates in meetings, training and in-service education, as required.
Current TX RN license in good standing. Bachelor's degree in Nursing or Related field preferred. LVNs will be considered depending on clinical experience.
Experience working in a Managed Care or Provider office setting; or HEDIS experience
Experience with Medicare HCC Risks and ICD-10 and CPT codes preferred
Must possess excellent written and verbal communication skills, and have demonstrated experience with presentations.
Must have experience with Microsoft Office (Word, Excel, and Power Point) and be proficient in working with computers and databases.
Must be able to collect, synthesize and analyze data and make recommendations to improve outcomes and meet goals
Must have excellent organizational skills, be able to work with minimal supervision, demonstrated leadership experience and have a team-oriented approach.
Detail oriented, be able to meet production standards, initiate new processes to improve quality care and train Providers as needed.
Must be Professional, have a good work ethic, be a conscientious problem solver and be results-oriented
Must be adaptable, willing to learn, and take personal pride in their work.
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.