Clinical Quality Manager
About the role
The Clinical Quality Manager works with members and providers to ensure they receive appropriate services, focusing on improving the quality of care through metrics like HEDIS, QARR, and Medicare Advantage Star measures. Responsibilities include interacting with hospitals, providers, and members to enhance care quality, reviewing billing codes, medical records, and claims submission processes for accuracy, attending and facilitating meetings involving targeted providers and measures, conducting on-site visits to implement work plans and educate providers on coding and documentation practices, collaborating with other departments to promote preventive services and chronic disease management, assisting in writing articles for newsletters related to HEDIS, QARR, Medicare Advantage, and health promotions, and supporting regulatory affairs as needed. Documentation of all relevant interactions is also required.
Responsibilities
- Interact with hospitals, providers, and members to improve quality of care
- Monitor progress and recommend changes
- Reviews billing codes, medical records, and claims submission process to ensure accuracy
- Attends and facilitates any initiative meetings involving targeted providers and/or measures
- Completes on-site visits to implement the work plan and conduct provider education sessions
- Collaborates with other departments to maximize member outreach for preventive services and chronic disease management
- Affords assistance in writing member and/or provider articles related to HEDIS, QARR, Medicare Advantage, and health promotions for the HF newsletter
- Supports regulatory affairs as deemed necessary by management
- Documents all relevant interactions in appropriate systems
Requirements
Commensurate with experience, education, licenses, and certifications.
Qualifications
Commensurate with experience, education, licenses, and certifications.
Skills
Not specified
Benefits
Not specified
Pay
Hiring Range: Greater New York City Area (NY, NJ, CT residents): $83,100 - $120,360
All Other Locations (within approved locations): $73,400 - $108,160
Schedule
Not specified