Job Description

Overview

This is a short-term assignment.

What you can expect!

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

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. This role interprets clinical data for QI-related studies for medical management. This position maintains a working knowledge of the current medical management systems, business processes and workflows. The HEDIS Improvement Nurse maintains summarized information for Quality Systems related to modified and new regulatory requirements for medical management from DHCS, DMHC and CMS.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Key Responsibilities

Act as a liaison between the QI/HEDIS department and other departments, practitioners, and providers to ensure basic understanding of HEDIS projects/issues

Train other departments on HEDIS related measures as needed

Participate in the development, research, and implementation of HEDIS improvement activities, as directed

Support and educate the QI/HEDIS Coordinator in CRM activities, HEDIS data entry, and all other applicable HEDIS related activities

Manage outreach and education projects related to HEDIS, Supplemental Data, and other quality improvement initiatives

Research and develop training materials, conduct presentations and information sessions, or provide targeted outreach about Historical Supplemental Data, NCQA HEDIS Technical Specifications, and other quality activities/medical record review projects

Review and perform quality assurance checks of supplemental data files (both manual and digital) throughout the year, ensuring 100% accuracy

Participate in medical record abstraction and accuracy validations (overreads) for HEDIS hybrid pursuit, maintaining subject matter expert status to assist other nurse reviewers

Maintain tracking system for regulatory changes to ensure QS management is apprised of significant modifications required

Maintain knowledge of various other data sources utilized by QS to assist with regulatory compliance.

Troubleshoot medical management report requests to determine user needs and objectives, working with users to correctly identify criteria

Participate in analysis, interpretation, and translation of complex clinical data, issues, trends, and relationships into effective strategies and action plans for medical management. Demonstrate a commitment to incorporate LEAN principles into daily work

Perform any other duties as required to ensure Health Plan operations and department business needs are successful

Qualifications

Education & Experience

• Three (3) or more years of any individual or combined experience in quality assurance, utilization management, case management, and/or health care informatics
• Experience in an HMO or managed care setting preferred
• Associate's degree in Nursing from an accredited institution required
• Bachelor's degree in Nursing from an accredited institution preferred
• Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required

Key Qualifications

• Advanced knowledge of NCQA HEDIS technical specifications, medical terminology, and health plan processes preferred
• Advanced knowledge of the current medical management systems and how information is stored and retrieved
• In-depth understanding of current HEDIS technical specifications with the ability to interpret changes and clarifications accurately
• Possess basic knowledge of Microsoft Access to look up Member data for purposes of verifying clinical services needed or received
• Data analysis and Computer applications, including word processing, databases, and spreadsheets
• Proficient in Microsoft Office Suite. Excellent interpersonal/communication skills
• Ability to handle multiple projects, data input, strong problem-solving capability
• Strong attention to detail

Start your journey towards a thriving future with IEHP and apply TODAY!

Work Model Location

Telecommute (All IEHP positions approved for telecommute work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership)

Pay Range

USD $91,249.60 - USD $120,910.40 /Yr.