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Excellus BlueCross BlueShield FEP Clinical Quality Measurement Coordinator I/II - 012721 in Rochester, New York

Under management guidance, this position is responsible for clinical quality activities, including but not limited to HEDIS / QARR / QRS process, clinical quality concerns, NCQA requirements, medical record reviews and clinical studies required by the Health Plan in support of regulatory requirements. In addition, the clinical team supports the goals, objectives and direction of the Health Care Improvement Department.

Essential Responsibilities/Accountabilities
All Levels
• Assists in the completion of the extensive reporting requirements for mandated reporting, such as HEDIS / QARR / QRS
• Documents all processes and procedures relating to current HEDIS hybrid review plan
• Develops, implements and monitors hybrid audit process to meet external audit requirements
• Uses clinical knowledge to assess the completeness and reliability of data and the validity and accuracy of clinical results for hybrid measures.
• Reviews, analyzes and completes all mandated clinical studies required by CMS, NYS DOH or other regulator
• Works collaboratively with internal and external customers to drive Health Care Improvement while educating on measures and performance.
• Performs detailed medical record documentation reviews for providers and reports to credentialing and appropriate internal committees
• Monitors and evaluates data from hybrid review results for reporting. Presents on program activities and performance internally.
• Supports and implements initiatives to support the Health Care Improvement Strategic Goals and Objectives.
• Embraces and leads change consistently demonstrating a positive can do attitude.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and Leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Clinical Quality Measurement
• Follows and updates as indicated, the clinical quality concerns process while working in tandem with the Medical Directors, and if indicated NYS Department of Health

FEP Clinical Quality Measurement
• Develops outreach plan/initiatives designed to improve member clinical quality measure results, including development of educational materials, scripting for interactive voice messaging or other methods of engagement.
• Educates FEP Team members regarding HEDIS/CAHPS measures, outreach plans, as well as, opportunities to improve member compliance/adherence to guidelines and standards for care during their interactions with members.
• Makes outreach calls to members for specific targeted interventions, including documentation in care management system as needed.
• Coordinates necessary ad hoc committees, meetings, and communications for Member Care Management quality initiatives

Level II - In addition to responsibilities in level I
• Leads outreach to internal department to drive quality improvements including but not limited to community wide improvement initiatives,
• Proactively researches best practice with other Health Plans in order to evaluate current programs, processes and complete rapid tests of change as needed
• Serves as a HEDIS QARR QRS Subject Matter Expert on process and clinical measures and proactively outreaches to educate both internal and external customers
• Reviews clinical data in partnership with Quality Measurement analysts to assess measure performance.
• Conducts medical best practice research, barrier and root cause analysis on identified high impact quality measures to identify potential member or provider interventions
• Prepares and presents outcome reports on program activities and performance to internal and external stakeholders, as indicated
• Anticipates regulatory changes through engagement with NCQA, CMS and NYS DOH and addresses accordingly.
• Leads process change and presents results on program activities, overall performance.
• Collaborates with other Health Plans, government payers, consultants, providers, BCBSA and other health care entities to identify availability and use of best practices relating to HEDIS hybrid reviews, quality and performance improvement initiatives, programs, and benchmarks.

Minimum Qualifications

Note of Classification
We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.
Level I
• Registered Nurse with current New York State License with Bachelor’s degree in relevant field with a minimum of three years progressive clinical experience in an acute care setting, including experience working with quality improvement programs, including technical and data analysis skills. In lieu of degree, a minimum of five years’ progressive experience in health care ambulatory setting or health related insurance position.
• Maintains thorough working knowledge of HEDIS / QARR / QRS measurement.
• Maintains current and thorough understanding of federal and state regulations and advancements put forth by quality improvement organizations, including but not limited to NCQA, CMS, and NYS DOH requirements.
• Knowledge of quality improvement methodologies
• Knowledge of health plan and physician offices.
• Strong problem solving skills. Ability to verify accuracy of data to report information correctly.
• Excellent written and verbal communication skills. Strong interpersonal and presentation skills.
• Ability to work with all Microsoft Office programs and databases for quality reporting.
• Ability to work independently as well as on intra- and interdepartmental teams.
• Must be able to interact with all levels of management, physicians and office staff.
• Comfortable and confident interacting with medical directors, providers, legal staff, NYS DOH, and federal regulators.
• Strong clinical background to guide problem solving related to quality concerns.
• Research skills to assist with the information gathering required to complete quality of care cases.

Level II - in addition to qualifications in level 1:
• Minimum 3 years of progressive HEDIS QARR QRS experience.
• Seasoned polished professional who is capable of interacting with providers, external regulators and Certified NCQA auditors.
• Recognized as a HEDIS QARR QRS subject matter expert.
• Exhibits strong organizational and planning skills. Ability to define or identify problems and prioritizes impact or corrective action/implementation to drive execution.
• Certified coder preferred.
• Knowledge of regulatory programs and the health insurance industry.
• Strong seasoned professional with highly developed critical thinking skills who is capable of interacting with internal departments, external regulators, and providers

Physical Requirements
• Must have ability to travel to providers throughout specific service area.