Quality Assurance

Overview

• Contribute to improving healthcare quality by addressing gaps in care and enhancing member education.
• Utilize data analytics to prioritize members needing preventive care and chronic condition management.
• Support initiatives to increase Medicare Star ratings and Medicaid Quality Incentive scores.
• Perform outreach calls to discuss health outcomes, preventive care, and mental health support.
• Collaborate with members to facilitate medical appointments and connect them with community resources.
• Contribute to the development and implementation of community health strategies.
• Maintain knowledge of HEDIS/QARR/Star measure technical specifications and guidelines.
• Provide clinical support and recommendations based on specific clinical criteria.
• Ensure compliance with clinical practice and preventive health guidelines.

Key Responsibilities & Duties

• Analyze data to identify members needing health education and care gap closure.
• Educate members on preventive care and chronic condition management.
• Make outreach calls to discuss health outcomes and preventive measures.
• Refer members to case management and assist with appointment scheduling.
• Collect, interpret, and present data related to outreach efforts and outcomes.
• Utilize HEDIS checklists to identify gaps in clinical service outcomes.
• Provide information to clinical staff to ensure adherence to guidelines.
• Facilitate quality improvement activities to enhance healthcare delivery.
• Perform additional tasks as directed or required to support healthcare initiatives.

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 including Word, Excel, and PowerPoint.
• Excellent communication skills for diverse audiences.
• Knowledge of outpatient medical practices and community resources.
• Experience in member outreach and preventive health education.
• Understanding of HEDIS/QARR/Star measure specifications.
• Ability to analyze data and contribute to healthcare quality improvement.
• Commitment to enhancing member health outcomes and satisfaction.