Manager, Clinical Quality, New York, NY

Employer Healthfirst Inc.
Created 06/09/2021
Reference 1079664
Job type Full Time
State NY
City New York
This position is responsible for improving the quality of care and services provided to our members, with a focus on HEDIS, QARR and Medicare Advantage Star measures. This position primarily works with network providers, but will also complete member outreach and education as needed to ensure members receive appropriate services.

- Lead and/or participate in interactions with all assigned network hospitals and large provider groups.
- Monitor provider-specific HEDIS report cards. Identify areas of concern, and raise concerns with management and hospital contacts.
- Provide assistance with root cause analysis related to low rates as needed, and develop an appropriate action /work plan. In addition, review billing codes and claims submission process at sites to ensure accuracy.
- Provide relevant information with regard to participating quality incentive programs. Monitor progress on monthly basis; prepare monthly dashboard reports and communicate with assigned hospitals and/or community groups about missing services lists.
- Maintain medical records department contacts, and knowledge of medical record/EMR systems. Facilitate/own retrieval of medical records.
- Attend and facilitate any initiative meetings (studies, partnerships) that involve targeted providers and/or measures.
- Complete on-site visits on a regular basis to implement the work plan, and to conduct provider education sessions regarding appropriate coding practices and chart documentation.
- Partner/ collaborate with network management representative, to understand broader HF provider initiatives underway with assigned providers.
- Partner with any on-site Medical Management staff to maximize member outreach for preventive services and chronic disease management, as appropriate.
- Participate in a large scope of Healthfirst initiatives and/or processes as directed by management.
- Assist in writing member and/or provider articles in relation to HEDIS, QARR, Medicare Advantage and/or health promotions for HF newsletter.
- Assist, collaborate and support the departmental needs, as deemed necessary by management.
- Contact provider offices to request and review charts in support of HEDIS & QARR reporting processes.
- Document all requests in appropriate systems, and work with management to overcome any barriers to retrieving charts. Maintain applicable retrieval, completion and accuracy standards.
- Additional duties as assigned

Minimum Qualifications:
  • Bachelor's degree from an accredited institution or equivalent work experience
  • Medical record review experience directly working on HEDIS/QARR in a managed care setting
  • Experience building and managing a team and leading work processes in a fast-paced environment
  • Experience setting direction for team and managing staff performance
  • Ability to travel around the NYC metro area based on business needs

Preferred Qualifications:
  • NYS RN, LPN, LMSW, or LCSW
  • Good presentation, relationship management, and analytical skills.
  • Intermediate MS Word, Excel, and PowerPoint.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

EEO Law Poster and Supplement

All hiring and recruitment at Healthfirst is transacted with a valid "@healthfirst.org" email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.

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