This position is responsible for establishing, monitoring, and updating data in performance measures of Universal Health Care’s managed care plans on the criteria of care and service.
The HEDIS Specialist is responsible for collecting, analyzing and reporting on data; as well as giving meaningful recommendations, and/or presentations, to management on specific areas of needed maintenance and improvements.
The HEDIS Specialist is the subject matter expert on all quality compliance standards from regulating agencies; as well as familiar with HIPAA privacy regulations. Conveys complex and/or technical information in a manner that others can understand, as well as understand and interpret complex information from others.
Skill Requirements and Preferences:
- Knowledge of all HEDIS Technical Specifications.
- Access and knowledge of the HOQ process and the oversight and completion of the Medicaid CAHPS.
- Knowledge of Managed Care Criteria for HEDIS submission.
- Liaison between the HEDIS vendor(s).
- Oversees the entire HEDIS Admin and Hybrid processes.
- Performs kick-off calls with both the HEDIS vendor (s) as well as our NCQA Certified Auditor.
- Collects all information needed for the HEDIS Roadmap submission and completes all follow-up action items if asked by NCQA Certified Auditor.
- Prepares and coordinates with interdepartmental staff the HEDIS on-site audit with our NCQA Certified Auditor.
- Coordinates with the internal HEDIS Data Management Team and HEDIS vendor on all Admin data submissions to ensure compliance. Including all admin refreshes.
- Ensures HEDIS Hybrid training to MRR Team.
- Ongoing monitoring of reporting metrics of all measures to determine any opportunities to improve.
- Prepares and completes the MRR Validation audit and submits to our NCQA Certified Auditor.
- Uploads all submissions in IDSS and validates all data uploaded.
- Coordinates with NCQA Certified Auditor to lock all plans on time.
- Coordinates with our internal HEDIS Data Management Team to submit PLD files on all HEDIS products submitted to NCQA.
- Coordinates and submits AHCA required Performance Measures with internal Data Management Team as well as HEDIS Vendor. Sends Performance Measures for audit to our NCQA Certified Auditor for audit prior to submission to the AHCA by July 1st annually.
- Completes and submits Quality Indicators annually to AHCA.
- Participates in the collection, organization, analysis, identification of improvement opportunities and reporting of data to evaluate and support quality improvement initiatives through trending of aggregate data.
- Designs spreadsheets that utilize statistical process control for trended Data.
- Directs all aspects of the HEDIS audit process including coordination with consultants, regulators and internal partners.
- Maintains that HEDIS strategic plan summaries are up-to-date at all times based on QM activities.
- Coordinates and performs medical record reviews to determine compliance to standards.
- Establishes, with management input, policy and procedures as it relates to HEDIS compliance.
- In conjunction with upper management, ensures proper contracting for HEDIS process.
- Other duties as assigned.
Educational Requirements and Experience:
- Experience with the systematic consolidation of data and report building.
- Excellent communication skills, must be able to effectively communicate, orally and written, to all constituents.
- Strong attention to detail.
- Problem solving and analytical acumen, with mathematical abilities for averages, statistics and percentages.
- Must be familiar with medical terminology and patient records.
- Knowledge base of clinical standards of care, preventive health standards, HEDIS, NCQA, governing and regulatory agency requirements, and the managed care industry.
- Bachelor's degree or equivalent combination of education and related experience, required.
- 3-5 years’ experience in a managed care setting, health plan or large medical group administration, required.
- LPN/RN, preferred.
- Medical coding experience, preferred.