Quality Assurance

Overview

• Support healthcare quality improvement by addressing care gaps and enhancing member education through proactive outreach and personalized guidance.
• Utilize data analytics to identify members needing preventive care and chronic condition management support.
• Engage members through outreach calls to discuss health outcomes and connect them with community resources.
• Collaborate with members to facilitate medical appointments and provide guidance on preventive care measures.
• Maintain up-to-date knowledge of healthcare quality standards, including HEDIS/QARR/Star measure specifications.
• Provide clinical recommendations based on established criteria to enhance member health outcomes.
• Ensure compliance with clinical practice standards and preventive health guidelines.
• Contribute to initiatives aimed at increasing Medicare Star ratings and Medicaid Quality Incentive scores.

Key Responsibilities & Duties

• Analyze data to identify members needing health education and care gap closure.
• Educate members on preventive care measures and chronic condition management strategies.
• Conduct outreach calls to discuss health outcomes and provide support for preventive measures.
• Refer members to case management services and assist with appointment scheduling.
• Collect, interpret, and present data related to outreach efforts and member engagement outcomes.
• Utilize HEDIS checklists to identify gaps in clinical service outcomes and recommend improvements.
• Facilitate quality improvement activities to enhance healthcare delivery and member satisfaction.
• Perform additional tasks as directed to support healthcare initiatives and organizational goals.

Job Requirements

• High School Diploma or GED required; BA/BS degree preferred.
• Minimum of 2 years of experience in medical or managed care environments.
• Proficiency in MS Office applications including Word, Excel, and PowerPoint.
• Strong communication skills for engaging diverse audiences effectively.
• Knowledge of outpatient medical practices and community resources.
• Experience in member outreach and preventive health education initiatives.
• Understanding of HEDIS/QARR/Star measure specifications and healthcare quality standards.
• Ability to analyze data and contribute to healthcare quality improvement projects.