This position is responsible for developing and coordinating HCS activities and interventions with the goal to improve the health of our members and the healthcare services of providers. This position would assist Corp CM/DM/HP in a continuous state of readiness surrounding HEDIS/QARR measures as well as assisting in maintaining ongoing compliance with state and federal rules and regulations.
Primary Job Duties:
- Responsible for coordinating required Corp CM/DM/HP Improvement programs within dept in relation to HEDIS/QARR.
- Responsible for submitting accurate reports on the status of programs. Analyzes data and prepares concise, accurate and meaningful HCS reports in accordance with company procedures. Assists in defining opportunities for improvement identified through analysis of trends and barriers, and communicates these appropriately
- Monitors, evaluates and documents case/disease/prevention management activities in conjunction with NCQA/URAC/HEDIS/DOH/STAR and other regulatory and accreditation requirements.
- Identify trends and training opportunities to improve overall compliance performance including data reporting, analysis, and investigation.
- Participate on and lead departmental and corporate teams as required for regulatory projects such as NCQA, NYSDOH, CMS, NYSDOI, HCR.
- Maintain knowledge of applicable, regulatory and accrediting requirements as they relate to Health Care Services, including Care Management and Quality process.
Bachelors Degree (Nursing)
- Registered Professional Nursing License or NYS recognized Qualified Health Care professional (ex. Licensed or certified CRC, CSW, PhD, OT, PT) required
- Previous Health Plan experience preferred
- Advanced proficiency in MS Excel, basic proficiency in MS Office applications
- Excellent time management skills
- Project management skills
- Excellent organizational skills and attention to detail
- Excellent verbal and written communication skills
- Strategic thinking/planning skills; must possess creative and critical independent thinking to take charge of assigned projects and the ability to work effectively with minimal supervision and oversight
- Ability to work effectively with minor supervision
- Prior experience in a fast-paced, face-to-face, customer service role working with daily deadlines and interruptions, is required
- High degree of business maturity and demonstrated confidentiality
- High energy level and ability to project enthusiasm
- Demonstrated change management and change catalyst competencies
- Demonstrated personal accountability
- Able to work with individuals and teams to meet common goals, as well as being self directed
- Knowledge of local and national Care Management and regulatory standards preferred, including NCQA / HEDIS/QARR reporting.
Or NYS recognized Qualified Health Care professional (ex. Licensed or certified CRC, CSW, PhD, OT, PT) required. At least five years clinical experience, two (2) of which must be in a hospital setting. Certified Case Manager (CCM) for case management development preferred.
- Must be able to work in an office environment
- Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively use a computer with all its components for prolonged periods of time and for the majority of required tasks
- Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively utilize various office equipment (phone, computer, fax machine, printer, copier, filing cabinet, etc)
- Registered Nurse
- Qualified Healthcare Professional