Quality Assurance

Overview

• Apply data analytics to identify members with care gaps, enhancing Medicare Star ratings and Medicaid Quality Incentive scores.
• Educate members on preventive care importance and chronic condition management for improved health outcomes.
• Conduct outreach calls to support Health Outcomes Survey initiatives, including fall prevention and mental health discussions.
• Collaborate with case management teams to facilitate member appointments and community resource connections.
• Contribute to community health strategies and activities for continuous quality improvement.
• Maintain knowledge of HEDIS/QARR/Star measure specifications to ensure compliance and effective outreach.
• Provide clinical support and recommendations based on measure-specific criteria.
• Document and present data insights from outreach efforts to drive quality improvement initiatives.

Key Responsibilities & Duties

• Analyze data to prioritize member outreach for health education and care gap closure.
• Assist members in accessing healthcare services and community resources.
• Conduct telephonic outreach to promote adherence to clinical practice and preventive health guidelines.
• Utilize HEDIS checklists to identify clinical service gaps and improve outcomes.
• Support quality improvement activities to enhance healthcare delivery to members.
• Provide insights and recommendations for outreach initiatives based on clinical criteria.
• Collaborate with clinical staff to ensure compliance with health guidelines.
• Perform additional tasks as required to support department objectives.

Job Requirements

• High School Diploma or GED required; BA/BS degree preferred.
• 2+ years of experience in medical or managed care environments.
• Proficiency in MS Office applications (Word, Excel, PowerPoint, Outlook, Teams).
• Strong communication skills for engaging diverse audiences effectively.
• Knowledge of outpatient medical services and community resources.
• Experience in preventive health education and resource coordination.
• Understanding of HEDIS/QARR/Star measure specifications preferred.
• Ability to analyze data and contribute to quality improvement strategies.