Clinical Quality Manager

Healthfirst; New York (NY); On-site; USD 73,000 - 120,000; Full time

Benefits offered by this job

Medical, dental, vision

401k contributions

Life insurance

Incentive & recognition programs

Employee wellness programs

Job summary

Healthfirst in New York seeks a Clinical Quality Manager to enhance care quality with a focus on HEDIS, QARR and Medicare Advantage Star measures. You will collaborate with hospitals, providers, and members to drive improvements in care delivery, coding accuracy, and documentation.

Responsibilities include educating providers, facilitating initiative meetings, and supporting regulatory affairs while ensuring timely record-keeping and provider communications.

Qualifications

• Associate’s degree from an accredited institution.
• Ability to travel around the NYC metro area
• Bachelor’s degree preferred
• Clinical license: LPN, RN, LMSW or LCSW
• HEDIS/QARR experience in managed care for Medicaid/Medicare
• Medical record review experience in HEDIS/QARR in managed care

Responsibilities

• Interact with hospitals, providers, and members to improve quality of care.
• Review billing codes, medical records, and claims submission processes for accuracy.
• Attend and facilitate initiative meetings involving targeted providers/measures.
• Conduct on-site provider visits to implement work plans and educate on coding/documentation.
• Collaborate with departments to maximize member outreach for preventive services and chronic disease management.
• Assist in writing member/provider articles on HEDIS/QARR/Medicare and health promotions.
• Support regulatory affairs and document all interactions in systems.

Skills

HEDIS/QARR

Analytical skills

Presentation skills

Relationship mgmt

MS Office

Education

Associate’s degree

Bachelor’s degree

Clinical license: LPN/RN/LMSW or LCSW

Tools

MS Word

MS 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

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

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

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 believes in providing a competitive compensation and benefits package wherever its employees work and live.

• The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.