Coordinate and support quality management, accreditation and compliance activities. Provide assessment and analysis of core processes and implementation of quality management activities in an effort to decrease administrative costs, while supporting member health improvement and assuring compliance with regulatory rules and accreditation standards. Serve as the resource to all levels within the organization, and is a subject matter expert within the quality management, accreditation and compliance activities.
This particular opening is being filled to focus on the Verisk HEDIS software application tool, providing primary accountability for the management of the interface of the Medical Record reviews onsite and in-office for HEDIS and hawk-I reporting. The incumbent will also support the independent HEDIS auditor process with the Road Map preparation and preparation of the over-read Medical Record Review process.
The incumbent also prepares the onsite Inter-rater review records and is responsible for actual data extraction in physician offices and clinics as well as training and assisting with Quality Assurance of the temporary HEDIS nurses that are employed annually during HEDIS audit season. This role supports the Physician Quality Metrics reporting and the Federal Employee Program HEDIS data extractions from FEP Direct, and gaps in care reporting. The position also supports the Quality Management analysis and day to day reporting and monitoring needs for the Quality Management Workplan. There is external interface with large clinic leadership in our provider networks, external auditors, and also internally with our network engagement staff.
Due to the duties of this position, the ideal candidate will have the ability to learn complex quality specifications, be intermediate to advanced with Microsoft excel and analytical concepts, and be able to effectively navigate an integrated data application used to measure HEDIS data.
Hiring Specifications Required:
Bachelor's Degree in Nursing, Business Administration, Health Care Administration or completion of an accredited nursing program
4 to 6 years of relatable experience:
Experience as Registered Nurse or related experience in a health care delivery/managed care setting, including experience in reading medical cases and literature and ability to draw defensible conclusions from the information; familiarity with physician practice patterns and billing practices, and knowledge of diagnosis and procedure coding system and how that applies to Wellmark business.
Experience in utilization management, quality management, or accreditation coordination.
Knowledge of health care industry and utilization management practices, including case and disease management, member certificates, and provider contracts.
Knowledge of URAC, NCQA, HEDIS accreditation standards, and state \federally mandated processes.
Strong familiarity with project management processes and methodology requirements.
Demonstrated ability to utilize excellent time management and project management skills.
Demonstrated analytical, diagnostic, and problem solving skills and statistical process control experience to identify root causes in complex situations, including the global level ability to view the “big picture” Proficiency with computers including word processing, spreadsheet, office administration, presentation and graphics software applications, preferably in a Microsoft environment.
Ability to evaluate financial impact of process and project initiatives including budget preparation and monitoring experience.
Excellent communication skills, including presentation, writing, meeting, and negotiation skills, including conflict resolution skills and excellent provider/broker relationship management experience.
Demonstrated strong team building skills including coaching, mentoring, facilitation, and process improvement skills.
Valid driver's license required.
Hiring Specifications Preferred:
Master's Degree in Nursing, Business Administration, Health Care Administration
CPHQ certification or Registered Nurse
Knowledge of all Wellmark operations
Experience utilizing Quality Management principles and techniques
1. Educate and engage Wellmark stakeholders on accreditation standards. This includes fully informing all Health and Care Management staff and appropriate owners of processes of accreditation and compliance requirements, and what specifically is required to stay compliant with said standards. Offer solutions and expertise in the process of compliancy.
2. Ensure Health and Care Management and Wellmark BCBS is in compliance with ERISA, applicable laws and regulatory compliance, in both Iowa and South Dakota. Includes oversight of business continuity processes in place for Health & Care Management.
3. Monitor, evaluate, measure and report compliance with ERISA, applicable laws and regulatory compliance in both Iowa and South Dakota with respect to member and provider appeals.
4. Participate and provide leadership information on process improvements for work processes.
5. Identify and implement quality management initiatives that promote the delivery of appropriate identified care, coordinated to preserve members benefit dollars as well as improving their health status.
6. Measure Wellmark Quality Improvement metrics with adherence to audit standards and technical specifications. Provide critical quantitative and qualitative analysis, identify opportunities for improvement identified and implement with subsequent measurement and analysis of the interventions that equip Wellmark, members and providers to manage the health care of our members, or internal processes or policies.
7. Develop Quality Improvement Programs(s), institute work plan(s), evaluate and report findings to the appropriate governing bodies annually.
8. Build work plans and desk levels for assigned work duties.
9. Perform other duties as assigned.
Wellmark Blue Cross and Blue Shield and its subsidiaries provide health coverage to more than 2 million members in Iowa and South Dakota....