Quality Coordinator-HTH

Position Purpose

The Quality Coordinator_HTH assists the Quality department in coordinating, developing, implementing, and measuring the quality programs for Hometown Health. The position will also provide support, education and engagement of members and network providers to ensure that the goals and objectives of the quality improvement plans are met.

This position performs, facilitates, and provides structure to ensure that clinical and non-clinical evidence-based quality improvement activities are being implemented. This position is also responsible for ensuring that the Quality Improvement program(s) are designed to support Hometown Health Quality initiatives. The position will ensure that quality improvement activities are directed toward analysis of data, with a focus on improvement of process and clinical outcomes.

This position will support the Quality Program to ensure compliance with all Federal and State laws and regulations (Centers for Medicare and Medicaid Services (CMS, Nevada Division of Insurance, and accrediting bodies)) and internal policies/procedures. The Quality Coordinator will implement system wide initiatives, policies and procedures and standard work related to the Quality Program and be responsible for program oversight, risk assessment, reports creation, communication strategy, and education/training and auditing/monitoring. This position will serve as a resource to support the Quality team in the general development of the Quality Program including, but not limited to, development and oversight of HEDIS workflows, Stars initiatives, monitoring/trending data for Quality Improvement Plans and Chronic Condition Improvement Programs, collaboration, and education to networked providers regarding Quality is Premium, and development of additional quality initiatives.

This position requires collaboration with departmental leadership and providers.

Nature and Scope

This position is responsible for improving network provider performance as measured by regulatory agencies overseeing programs such as HEDIS, CAHPS, HOS and plan CMS Star ratings. The position will involve medical record review, CMS, NCQA regulation research, and IT specification review for accurately educating and supporting healthcare providers to optimize the performance on all health plan quality initiatives. The position will utilize new technology, as appropriate, for efficient delivery of services and to make informed decisions based on data, to drive performance metrics across all health plan performance initiatives.

The position will provide support with managing the development, implementation, compliance, and oversight of Hometown Health’s Quality Improvement Programs. Components of this position include accreditation, Risk Adjustment, Stars, HEDIS, and Member Satisfaction. This position will perform other duties as requested.

The essential functions of the position are:

• Uses clinical knowledge to identify best practices and opportunities to collaborate, educate, and engage networked providers, office staff and internal stakeholders on all health plan performance initiatives that support regulatory requirements for programs such as HEDIS, CAHPS and plan Star ratings.

• Focuses organizational efforts on the improvement of clinical quality performance measures and identifies population-based member barriers to care. Works with the Quality team to identify local-level strategies to overcome barriers and close clinical gaps in care.

• General knowledge of health insurance, Managed Care, Benefit Design, Nevada Revised Statutes (NRS), Nevada Administrative Codes (NAC), Medicare Advantage Prescription plans (MA-PD) and Federal Regulations.

• Knowledge of Vendor Oversight Program to include analyzing risk assessments, performing audits, creating reports, educating, and following up with the business area to ensure processes exist to demonstrate compliance with delegation and vendor oversight requirements for the Plan.

• Work with internal and external programs to run reports, summarize performance data, identify opportunities, and relate information effectively to providers and management.

• Supports quality improvement programs by requesting records from providers, maintaining databases, and researching to identify members' provider encounter history

• Participates in and represents plan at community, collaborative and other organizational meetings focusing on quality improvement, member education, and disparity programs, as assigned

• Demonstrate the ability to analyze reports, documents, and spreadsheets.

• Excellent organization, problem solving, and analytical skills

• Ability to review, analyze, and interpret regulatory requirements in a clear and concise manner.

• Ability to work independently with minimal supervision.

The essential functions related to the HEDIS/Stars process include:

• Planning, organizing, and coordinating HEDIS data abstraction activities to include, but not limited to:

• Scheduling and coordinating on-site medical record reviews

• Conducting medical record reviews

• Uploading or data entering outcomes

• Provide technical support to HEDIS staff. Ensuring that HEDIS processes and outcomes comply with all applicable accreditation standards and regulatory requirements.

• Provide support to Quality Improvement Projects and Performance Improvement Projects aimed at improving HEDIS/Stars rates

This position shall participate all in quality improvement and change management procedures and processes.

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

This position will assist in completing care gaps such as retinopathy eye exams, bone density scans, FIT tests, lab work, blood pressures, etc. during Hometown Health Wellness Fairs as well as at local healthcare provider office events.

This position does not provide patient care

Disclaimer

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Minimum Qualifications

Requirements - Required and/or Preferred