- Direct Placement
- Quality Assurance
- Alhambra, CA
Quality Care Improvement Specialist
The QCI Specialist is responsible in providing department support by working with our network providers in improving the quality of care through quality improvement activities that will encompass HEDIS, CMS Star Rating, and health plan quality performance reporting. The duties and responsibilities will apply to all IPAs managed by Network Medical Management.
The Quality Care Improvement Specialist is responsible in supporting the healthcare delivery practice transformation with providers and staff to support physician practices with redesigning clinic based care delivery that allow the practice to implement care on a population based level, improve patient experience and transition to reimbursement for better healthcare outcomes through quality care. The role is designed to serve as the key driver in coordinating the necessary trainings to improve quality measures, change management, analytics and evidence based clinical processes under the new standards of care for provider practices.
Comply with department policy and procedures
Collecting and collating appropriate data from IPA network providers for HEDIS measures
Advise and coach provider practices on CMS guidelines for Star Measures (Part C & D)
Collect medical records, conduct reviews and ensure accuracy of documentation for reporting
Collect, summarize and trend provider performance data to include provider education
Participating in ongoing discussions concerning data collections and analysis for HEDIS
Assist in planning and implementation of projects to improve delivery of services and quality of care
Understand the principles of CMS, HEDIS, NCQA, Health Plan Quality Standards and HIPAA
Provide in-service training to providers regarding HEDIS and CMS Star Measures
Attend to provider and interdepartmental calls in accordance with exceptional customer service
Promotes a positive working relationship between NMM, IPA's and health plan
Establish trust with and interfaces regularly with project team and leaders
Responsible for all Practice Coaches required activities and performance as needed; Attend all relevant PTI trainings
Support the providers in preparing infrastructure for quality management implementation through activities such as advising on team-building, improving communication, facilitating meetings and helping to develop leadership skills
Communicates the vision for change through activities such as presenting best practices and standards of quality of care with preventive care program, HEDIS, and Star measures.
Assess physician practices by utilizing Physician Assessment Tool (PAT) and physician profile
Consults with and enable physicians at each phase of improvement (i.e., setting goals, thought partnership and recommending strategies or innovations, and execution) by providing tools, trainings, guiding them through rapid-cycle tests of change, and assisting when obstacles arise.
Aids practices in customizing processes to fit their own situation and incorporating the changes into their day-to-day routines for increased likelihood of sustainability
Responsible in providing a pleasant and professional customer service experience to all external and internal customers
Conduct Provider Training (PCPs& Specialist) that would include but not limited to:
- Practice Coach – Practice Transformation Initiatives
- Provider Manuals
- Web Portal
- UM and Claims Department process
Attend to health plans, provider, and interdepartmental calls in accordance with exceptional customer service; maintain professional and appropriate behavior (actions/verbal) at all times
Performs other duties, projects, and actions as assigned.
- Associate's degree or equivalent experience
- Five years of IPA/MSO or general healthcare experience with management experience preferred
- Bilingual and fluent in the language spoken and written
- Working knowledge of managed care and health plan standards
- Excellent analytical critical reasoning and interpersonal communication skill.
- Must exhibit efficiency, collaboration, candor, openness, and results orientation
- Ability to understands and explain data reports in different ways to practitioners
- Knowledge of practice management and/or financial aspects of the practice
- Experience with and understanding of the outpatient clinical setting
- Excellent presentation, verbal and written communication skills, and ability to collaborate with co-workers, senior leadership, and other management.
- Proven ability to prioritized and organize multi-faceted/multiple responsibilities simultaneously in a fast paced, changing environment while meeting deadlines and turnaround time requirements.
- Must be able to work independently utilizing all resources available while staying within the boundaries of duties.
- Must possess the ability to educate and train provider office staff members
- Ability to keep a high level of confidence and discretion when dealing with sensitive matters relating to providers, members, business plans, strategies and other sensitive information is required.
- Must be ethical and possess the ability to remain impartial and objective.
- Must be able to travel at least 75% of work time.
- Proficient with Microsoft applications.
$21 – $24
Full Time / Direct Hire