Quality Improvement Specialist (HEDIS) II

About the role

Takes a lead role in the development and maintenance of quality improvement related projects specific to HEDIS Hybrid Operations. Serves as the primary owner for assigned HEDIS measures and leads complex quality improvement initiatives to support the health plans.

Responsibilities

• Train providers, health plans and staff in methodologies and tools of continuous quality improvement and HEDIS abstraction and over-read processes.
• Provide clinical support to the medical record abstraction, over-read and audit processes.
• Monitor performance on established contractual quality indicators.
• Analyze, track and trend results.
• Prepare for and participate in meetings with various committees, state agencies, providers, health plans, vendors, and stakeholders.
• Recommend, develop, and implement quality performance improvement plans (PIPs) with management utilizing the PDSA model.
• Monitor and report PIPs progress through closure.
• Serve as primary owner for assigned HEDIS measures, including year-round pseudo-claims performance, gap identification, and intervention and strategy planning.
• Support department leadership in project and strategy development; lead quality improvement initiatives involving complex or high-risk HEDIS measures with market-wide impact.
• Provide functional and technical knowledge regarding overall program requirements and operations.
• Provide guidance on complex abstraction scenarios, team training, and measure interpretation using critical clinical abstraction knowledge.
• Demonstrate advanced proficiency across all phases of clinical medical record abstraction, including data entry, over read, and inter-rater reliability (IRR/third level over read), while serving as a mentor and resource to team members by providing guidance on measure interpretation, abstraction standards, and quality improvement best practices.
• Perform other duties as assigned.
• Comply with all policies and standards.

Requirements

• Bachelor’s degree in Nursing, Healthcare, or Quality (including HEDIS measures or NCQA) or equivalent experience in related healthcare experience.
• 2+ years of experience in Quality.
• Knowledge of HEDIS & performance measures strongly preferred.

Pay

$70,100.00 – $126,200.00 per year