QI Specialist I

Job Title: QI Specialist
Location: Remote (Preferred in TX)
Durations: 3 Months
Payrate: 37.84/hr. on W2

Description:
100% REMOTE BUT LOCATED IN TEXAS IS PREFERRED
POSITION OPENING IS DUE TO RADV AUDIT REQUIREMENT FOR HEALTHPLAN
ROLE IS FOR A PROVIDER ENGAGEMENT SPECIALIST
MUST WORK 8AM TO 5PM CST MONDAY TO FRIDAY

Job Summary:
The Provider Engagement Specialist, role implements Health Plan provider engagement strategy to achieve positive quality and risk adjustment outcomes through effective provider engagement activities.
Ensures the smaller, less advanced Tier 2 and Tier 3 providers have engagement plans to meet annual quality and risk adjustment goals. Drives coaching and collaboration with providers to improve performance through regular meetings and action plans.
Addresses practice environment challenges to achieve program goals and improve health outcomes. Tracks engagement activities using standard tools, facilitates data exchanges, and supports training and problem resolution for the Provider Engagement team. Communicates effectively with healthcare professionals and maintains compliance with policies.

Job Duties
Ensures assigned Tier 2 & Tier 3 providers have a Provider Engagement plan to meet annual quality & risk adjustment performance goals.
Drives provider partner coaching and collaboration to improve quality performance and risk adjustment accuracy through consistent provider meetings, action item development and execution.
Addresses challenges/barriers in the practice environment impeding successful attainment of program goals and understands solutions required to improve health outcomes.
Drives provider participation in Client risk adjustment and quality efforts (e.g. Supplemental data, EMR connection, Clinical Profiles programs) and use of the Client Provider Collaboration Portal.
Tracks all engagement and training activities using standard Client Provider Engagement tools to measure effectiveness both within and across Client Health Plans.
Serves as a Provider Engagement subject matter expert; works collaboratively within the Health Plan and with shared service partners to ensure alignment to business goals.
Accountable for use of standard Client Provider Engagement reports and training materials.
Facilitates connectivity to internal partners to support appropriate data exchanges, documentation education and patient engagement activities.
Develops, organizes, analyzes, documents and implements processes and procedures as prescribed by Plan and Corporate policies.
Communicates comfortably and effectively with Physician Leaders, Providers, Practice Managers, Medical Assistants within assigned provider practices.
Maintains the highest level of compliance.
This position may require same day out of office travel approximately 0 - 80% of the time, depending upon location.

REQUIRED QUALIFICATIONS:
Associate’s degree or equivalent combination of education and work experience.
1-3 years experience in healthcare with minimum 1 year experience improving provider Quality performance through provider engagement, practice transformation, managed care quality improvement, or equivalent experience.
Working knowledge of Quality metrics and risk adjustment practices across all business lines
Demonstrates data analytic skills
Operational knowledge and experience with PowerPoint, Excel, Visio
Effective communication skills
Strong leadership skills"

Summary:
Responsible for developing, organizing, collecting, coordinating, preparing and presenting results of quality improvement studies and projects activities to monitor, evaluate and continuously improve the quality of healthcare services provided to Client member.

Essential Functions:
Collaborates with the Quality Improvement department staff in the development of quality improvement studies, initiatives and projects to improve the health care of members.
Plans and coordinates the collection, evaluation and dissemination of quality improvement data for quality initiatives, studies and projects to comply with regulatory requirements and accreditation standards.  
Prepares reports and analyses to evaluate performance with standards from a variety of sources such as and not limited to: materials, documents, medical charts, provider offices, and/or facilities.  
Performs with qualitative and quantitative analysis to identify significant and problematic clinical issues and concerns, development of improvement plans and measurement to assess impact of actions.  
Participates in NCQA accreditation and regulatory audit preparedness and maintains activities including preparing reports, narratives, graphs, charts, etc. as needed for external audits and surveys.  
Participates in and facilitates quality improvement program committees, as assigned, including preparing materials, minutes and tracking action items for committee review.  Develops and maintains Quality Improvement department policies and procedures, materials and reports in accordance with State, Federal, and NCQA and Client requirements. State Plan / Department

Specific Duties and Responsibilities  
Performs audits of materials and medical records to demonstrate compliance with contractual obligations, identify opportunities for improvement, and to validate medical record-keeping practices for credentialing and recredentialing purposes.  
Collects HEDIS data and/or Ambulatory Medical Record Review Data through chart review of medical records (medical record abstraction) as directed.  
Supports various HEDIS activities as needed.  t
Reviews, identifies and trends quality of care issues, serious reportable adverse conditions and assists in the implementation of corrective action plans.  
Participates in the development of materials as needed for member and provider quality initiatives such as HEDIS, improvement projects, and studies.

Knowledge/Skills/Abilities:
Proficiency with PC-based systems  
Excellent verbal and written communication skills  Ability to abide by Clients policies  Ability to maintain attendance to support required quality and quantity of work  Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)  Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers

Required Education:
Bachelors Degree in Public Health or related healthcare field (equivalent experience in lieu of a Bachelors)

Required Experience: 
0-2 years experience in Quality Improvement. 0-2 years experience in managed care or healthcare industry.  
Experience with qualitative or quantitative projects/analysis.

Required Licensure/Certification: May require an RN/LPN for some State Plans.