Clinical - Quality Improvement Specialist (HEDIS)

Spectraforce Technologies, Inc.; Raleigh (NC); Remote; USD 70,000 - 100,000; Part time

Job summary

Spectraforce Technologies, Inc. is seeking a Quality Improvement Specialist (HEDIS) to support clinical record review for health plans. The role emphasizes NCQA/HEDIS measures, data analysis, and development of improvement plans using PDSA methodologies.

Remote work with nationwide project support; requires nursing/quality background and strong technical skills. Responsibilities include training providers, auditing records, tracking performance indicators, and collaborating with committees and

Qualifications

• BSN, healthcare, or quality background with HEDIS/NCQA knowledge.
• Experience with HEDIS/NCQA gap closure preferred.
• Knowledge of NCQA technical specifications.

Responsibilities

• Train providers and staff in QI methodologies and HEDIS processes.
• Provide clinical support for medical record abstraction and audits.
• Monitor quality indicators and track performance
• Prepare for meetings with committees and health plans
• Develop and implement PIPs using PDSA model

Skills

NCQA/HEDIS knowledge

Clinical quality improvement

Data analytics

Excel

Education

Bachelor's degree in Nursing/Healthcare/Quality

Tools

Excel

Word

MS Office Suite

Job description

Position Title: Quality Improvement Specialist (HEDIS)

Work Location: Remote-Arkansas (Can source nationwide)

Assignment Duration: 6 months

Work Schedule: 8-5 CST Mon - Fri No OT and holiday

Work Arrangement: Remote

Position Summary

• Support the development and maintenance of quality improvement related projects specific to HEDIS Hybrid Operations. The position exists to support the health plans in the clinical aspect of medical record review.
• Background & Context: Needed to support year end push initiatives for HEDIS team - to complete the year round measures specific projects needed to close gaps prior to the year end cutoff and then transition to supporting the hybrid project that includes 12 projects and medical record requests/reviews to increase star ratings across all the health plan lines of business.

Key Responsibilities

• Train providers, health plans and staff in methodologies and tools of continuous quality improvement and HEDIS abstraction and over-read processes
• Provide clinical support to the medical record abstraction, over-read and audit processes
• Monitor performance on established contractual quality indicators.
• Analyze, track and trend results
• Prepare for and participate in meetings with various committees, state agencies, providers, health plans, vendors, and stakeholders
• Recommend, develop, and implement quality performance improvement plans (PIPs) with management utilizing the PDSA model.
• Monitor and report PIPs progress through closure.
• Performs other duties as assigned
• Complies with all policies and standards

Qualification & Experience

• Bachelor's degree in Nursing, Healthcare, or Quality (including HEDIS measures or NCQA) or equivalent experience in related healthcare experience.
• Valid state clinical license preferred (i.e.- LPN, RN, etc.)
• Experience in HEDIS or NCQA or related topics preferred
• NCQA experience with HEDIS gap closure.
• Additional qualities: quality improvement, medical coding, data analytics, and compliance understanding
• Top hard skills: Knowledge of NCQA technical specifications and how to navigate and utilize them; Medical Terminology skills; Technical skills, excel, word and Microsoft office suite

Candidate Requirements

Education/Certification

Required: Bachelor's degree in Nursing, Healthcare, or Quality (including HEDIS measures or NCQA) or equivalent experience in related healthcare experience.

Preferred:

Licensure

Required:

Preferred:

Years of experience required: NCQA experience with HEDIS gap closure.

Disqualifiers:

Additional qualities to look for: quality improvement, medical coding, data analytics, and compliance understanding

Top 3 must-have hard skills stack-ranked by importance

• 1
• Knowledge of NCQA technical specifications and how to navigate and utilize them
• 2
• Medical Terminology skills
• 3
• Technical skills, excel, word and Microsoft office suite

Candidate Review & Selection

• Shortlisting process
• Candidate review & selection
• Interview information
• Onboard process and expectations

Projected Manager Candidate Review Date: 1-2 days post shortlisting

Type of Interviews: Teams, phone, etc.