Quality Assurance Specialist

Overview

• Apply data analytics to identify members with care gaps to improve healthcare quality metrics.
• Educate members on preventive care and managing chronic conditions effectively.
• Support outreach initiatives to enhance Health Outcomes Survey results.
• Collaborate with clinical staff to ensure compliance with healthcare guidelines.
• Utilize HEDIS checklists to identify and address clinical service gaps.
• Contribute to community health strategies and quality improvement activities.
• Maintain knowledge of healthcare quality measures and technical specifications.
• Provide clinical support and recommendations based on measure criteria.

Key Responsibilities & Duties

• Analyze data to prioritize members for health education and care gap closure.
• Conduct outreach calls to discuss preventive care and health improvement strategies.
• Refer members to case management and assist with appointment scheduling.
• Interpret and present data related to outreach outcomes and quality improvement.
• Collaborate on initiatives to enhance community health strategies.
• Ensure compliance with clinical practice and preventive health guidelines.
• Provide information to clinical staff to support healthcare quality improvement.
• Perform additional tasks as required to support organizational goals.

Job Requirements

• High School Diploma or GED; BA/BS degree preferred, master’s ideal.
• Minimum 2 years of experience in medical or managed care environments.
• Proficiency in MS Office applications (Word, Excel, PowerPoint, Outlook, Teams).
• Knowledge of outpatient medical structures and community resources.
• Strong communication skills for diverse audiences and member interactions.
• Experience in preventive health education and resource connection.
• Understanding of HEDIS/QARR/Star measure specifications.
• Ability to contribute to quality improvement and community health strategies.