*Position Summary/Position*
Under the direction of the Supervisor, Clinical Quality Improvement, the HEDIS Improvement Nurse provides support to the Supervisor, Clinical Quality Improvement and IEHP departments on HEDIS improvement related issues, serving as a resource for internal and external customers. Is able to interpret clinical data for QI-related studies for medical management. This position maintains a working knowledge of the current medical management system (MedHOK), business processes and workflows. Maintains summarized information for Quality Systems related to modified and new regulatory requirements for medical management from DHCS, DMHC and CMS.
*Major Functions (Duties and Responsibilities)*
1. Responsible for understanding current HEDIS technical specifications with the ability to interpret changes and clarifications accurately.
2. Acts as a liaison between the QI/HEDIS department and other departments, practitioners, and providers to ensure basic understanding of HEDIS projects/issues.
3. Responsible for participating in the development, research, and implementation of HEDIS improvement activities, as directed.
4. Trains other departments on HEDIS related measures, as needed.
5. Responsible for assisting the PMI Manager with the HEDIS Improvement Committee (HIC) agenda, maintaining the Action Tracking log, writing HIC minutes, monitoring attendance, ensuring follow up activities are addressed by all departments and submitted timely for the next HIC.
6. Reviews and performs quality assurance checks of supplemental data files (both manual and digital) throughout the year, ensuring 100% accuracy.
7. Participates in medical record abstraction and accuracy validations (overreads) for HEDIS hybrid pursuit, maintaining subject matter expert status to assist other nurse reviewers.
8. Maintains tracking system for regulatory changes to ensure QS management is apprised of significant modifications required.
9. Responsible for maintaining knowledge of various other data sources utilized by QS to assist with regulatory compliance.
10. Maintains a working knowledge of the current medical management system (MedHOK) and how information is stored and retrieved.
11. Able to troubleshoot medical management report requests to determine user needs and objectives, working with users to correctly identify criteria.
12. Participates in analysis, interpretation, and translation of complex clinical data, issues, trends, and relationships into effective strategies and action plans for medical management.
13. Supports and educates the QI/HEDIS Coordinator in CRM activities, HEDIS data entry, and all other applicable HEDIS related activities.
14. Possess basic knowledge of Microsoft Access to look up Member data for purposes of verifying clinical services needed or received. This helps ensure timely processing of Oracle CRM tasks.
15. Establishes and maintains effective working relationships with others throughout the organization as well as external customers.
16. Responsible for managing assigned projects and effectively communicating with PMI Manager if any project deadlines will not be met, well in advance of the project due date.
17. Demonstrate a commitment to incorporate LEAN principles into daily work.
*Experience Qualifications*
Three (3) or more years of any individual or combined experience in quality assurance, utilization management, case management, and/or health care informatics is required.
*Preferred Experience*
Experience preferably in an HMO or managed care setting.
*Education Qualifications*
Associates in Nursing from an accredited institution required.
*Preferred Education*
Bachelor's in Nursing from an accredited institution preferred.
*Professional Licenses*
Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN
*Knowledge Requirement*
Working knowledge of NCQA HEDIS technical specifications, medical terminology, and health plan processes preferred.
*Skills Requirement*
Data analysis, word processing, spread sheet (Excel) and some database capabilities. Excellent interpersonal/communication skills.
*Abilities Requirement*
Ability to handle multiple projects, data input, strong problem-solving capability. Strong attention to detail.
*Commitment to Team Culture*
The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.
Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region, designated as “Great Place to Work.” With a provider network of more than 5,000 and a team of more than 3,000 employees, IEHP provides quality, accessible healthcare services to more than 1.5 million members. And our Mission, Vision, and Values help guide us in the development of innovative programs and the creation of an award-winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and make a difference with us! IEHP offers a competitive salary and stellar benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and state pension plan.
Job Type: Full-time
Pay: $43.87 - $58.13 per hour
Benefits:
* 401(k)
* Dental insurance
* Flexible schedule
* Flexible spending account
* Health insurance
* Health savings account
* Life insurance
* Paid time off
* Professional development assistance
* Retirement plan
* Tuition reimbursement
* Vision insurance
Schedule:
* 8 hour shift
* Day shift
* Monday to Friday
Education:
* Associate (Required)
Experience:
* quality assurance, utilization management, case management: 3 years (Required)
* NCQA HEDIS: 3 years (Required)
* Medical record review: 3 years (Required)
Work Location: Hybrid remote in Rancho Cucamonga, CA 91730