Clinical Quality Manager

Healthfirst; Layton (UT); On-site; USD 83,000 - 120,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

401k contributions

Incentive and recognition programs

Life insurance

Job summary

Healthfirst is seeking a Clinical Quality Manager to work with members and providers to enhance the quality of care, focusing on HEDIS, QARR, and Medicare Advantage Star measures.

The role involves coordinating with hospitals and providers, reviewing coding and records, and educating providers on best practices to drive improvement and compliance across populations.

Qualifications

• Associate’s degree from an accredited institution.
• Ability to travel around the NYC metro area.
• Bachelor’s degree preferred; clinical license may be preferred depending on role.

Responsibilities

• Interacts with hospitals, providers, and members to improve quality of care, monitor progress, and recommend changes.
• Reviews billing codes, medical records, and claims submission processes to ensure accuracy.
• Attends and facilitates initiative meetings involving targeted providers and/or measures.
• Completes on-site provider visits to implement work plans and conduct provider education sessions on coding and documentation.
• Collaborates with other departments to maximize member outreach for preventive services and chronic disease management.
• Assists in writing member/provider articles on HEDIS, QARR, and Medicare/health promotions.
• Assists and supports regulatory affairs.
• Documents all relevant interactions in appropriate systems.
• Additional duties as necessary.

Skills

HEDIS review

Quality improvement

Regulatory compliance

Data analysis

Provider education

Education

Associate’s degree

Bachelor’s degree preferred

Tools

MS Word

Excel

PowerPoint

Job description

The Clinical Quality Manager works with members and providers to ensure members receive appropriate services. This role emphasizes improving the quality of care with a focus on HEDIS, QARR and Medicare Advantage Star measures.

Duties & Responsibilities

• Interacts with hospitals, providers, and members to improve quality of care, monitor progress, and recommend changes
• Reviews billing codes, medical records, and claims submission processes to ensure accuracy
• Attends and facilitates any initiative meetings (studies, partnerships) that involve targeted providers and/or measures
• Completes on-site provider visits to implement work plans and conduct provider education sessions regarding appropriate coding practices and chart documentation
• Collaborates with other departments to maximize member outreach for preventive services and chronic disease management
• Assists in writing member and/or provider articles on HEDIS, QARR, Medicare Advantage, and/or health promotions for the HF newsletter
• Assists and supports regulatory affairs
• Document all relevant interactions in appropriate systems
• Additional duties as necessary

Minimum Qualifications

• Associate’s degree from an accredited institution
• Ability to travel around the NYC metro area

Preferred Qualifications

• Bachelor’s Degree from an accredited institution
• Clinical license: LPN, RN, LMSW or LCSW
• Multiple years of HEDIS review experience for both Medicaid and Medicare lines of business
• Medical record review experience directly working on HEDIS/QARR in a managed care setting
• Good presentation, relationship management, and analytical skills
• Intermediate MS Word, Excel, and PowerPoint

Compliance & Regulatory Responsibilities: Noted above

License/Certification: N/A

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified.

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 [e-mail] 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.

Thank you for considering a career with HF Management Services, LLC.

Know Your Rights

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.

Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $83,100 - $120,360. All Other Locations (within approved locations): $73,400 - $108,160.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements).

Healthfirst is New York’s largest not-for-profit health insurer offering it’s nearly 1.7 million members access to high-quality, affordable healthcare. As part of the community for nearly 30 years, Healthfirst’s unique advantage is rooted in its belief that good health doesn’t start in a doctor’s office. The company’s mission is to put its members first by working closely with care providers and community leaders to address broader issues that can impact health and well‑being. This value‑based care model is the foundation of the company’s sustained growth in one of the most dynamic markets in the country. So, if you are passionate about what you do and want to work for a company that is focused on the future and dedicated to making a difference in people’s lives, then Healthfirst is for you.