Highmark Health Clinical Quality Management Consultant- HEDIS in Helena, Montana
Job Description :
This job works within the Quality Department to facilitate accurate and complete collection and submission of annual HEDIS data following all NCQA prescribed definitions and regulatory processes.
The incumbent will conduct data collection and abstraction of medical records for the annual HEDIS project including supplemental data collection and review. C onduct quantitative and qualitative analyses related to Health Plan performance on the HEDIS measures. W ork collaboratively with the Quality team and appropriate stakeholders on enterprise quality initiatives supporting gap closure, member experience (CAHPS) and member outcomes activities in a matrix relationship.
Develop, oversee and manage large projects targeting members and/or network providers to improve clinical care provided to health plan members, including data analysis; visualizing and resolving complex issues and developing and implementing interventions. Perform review of medical record documentation, practice guideline development and monitoring, network provider performance measurement and monitoring, activities to educate or influence the behavior of members and/or providers, etc.Perform web base reviews of research, best practices, professional guidelines, health education and any additional resources for clinical analysis purpose.
Coordinate and monitor the specific quality improvement programs to maintain regulatory compliance and quality accreditation for the corporation.
Fulfill the role of subject matter expert for the corporation regarding activities related to applicable quality standards and assigned accountabilities. Organize and provide consultative support to relevant corporate stakeholders. Facilitate work-groups on various activities to ensure compliance and implementation of services.
Promote a culture of performance excellence by enhancing job skills through quality process improvement and tools training / certification; participating in process and operational initiatives and building and maintaining effective relationships throughout the organization to advance Performance Excellence.
Other duties as assigned or requested.
- Bachelor's Degree in Nursing
- Licensed Registered Nurse with 6 years experience
3 - 5 years in Nursing
1 - 3 years in Quality Improvement
1 - 3 years in Research and Development
2 – 3 years HEDIS experience, analyzing HEDIS metrics preferred
1 – 3 years in Clinical Setting
1 – 3 years Member Experience (CAHPS surveys)
1 – 3 years Population Health
LICENCES AND CERTIFICATIONS
- Registered Nurse
Written & Oral Presentation Skills
Language (other than English)
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Does Not Apply
Lifting: 25 to 50 pounds
Does Not Apply
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Pay Range Minimum:
Pay Range Maximum:
Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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Req ID: J216548