Primary Purpose:

Provide support to the risk and quality team, IPA Administrators, VP of Clinical Services on Clinical Initiatives to improve patient outcomes and group quality measures in Risk Adjustment, CMS 5 Star as well as the commercial and MediCal programs.

Principal Duties and Responsibilities (* = essential functions):

• Outreach and coordinate care for IPA members who are in need of preventative and/or chronic care services such as mammograms, colonoscopies, uncontrolled HbA1c, uncontrolled blood pressure, etc.
• Collaborate with Risk Adjustment and quality on provider education.
• Maintain knowledge of clinical initiative and risk adjustment program requirements
• Maintain knowledge of 5 Star performance and risk adjustment factors for all IPAs.
• Collaborate with health plans on 5 Star, commercial and MediCal gap reports.
• Coordinate outreach to PCP offices on member due reports including No Annual Visits list.
• Provide PCP offices with ongoing education of quality measures
• Work with health plans to provide supplemental data
• To contribute to a fair and positive work environment. *
• To perform other duties as assigned.
• Review, monitor and track the medical record retrieval reports to identify provider issues such as but not limited to, refusals to comply with medical record requests.
• Identifies and follows through on potential issues affecting Risk Adjustment projects.

Job Specifications (KSAs):

• Requires knowledge of managed care processes as is generally acquired by 1 or more years of experience in a Health Plan, IPA or Medical Group environment.
• Requires the ability to communicate clearly and effectively in both verbal and oral modes with both internal and external customers.
• Requires an understanding of medical terminology as is generally acquired through a relevant course, or 2 years or more in a medical office setting or utilization management department.
• Requires fast, accurate typing skills and proficient level computer software competency, including Word, Excel

• Consistently produces accurate and timely work as it relates to departmental goals.
• Demonstrates high reliability through consistent punctuality and attendance.
• Competently performs position requirements with minimal supervision and direction, including taking initiative and assuming responsibility for follow through.
• Uses sound judgment with regard to time management and prioritization of work to balance multiple tasks and meet required timeframes for all administrative activities as required.
• Demonstrates excellent interpersonal skills as discerned through observation and team project successes.
• Accurately interprets and applies departmental policies and procedures using sound judgment.
• Communicates clearly, professionally and respectfully to peers, superiors, subordinates and clients.
• Provides constructive feedback on work projects assigned.
• Demonstrates overall professionalism in attitude, demeanor and personal appearance