Clinical Quality Manager

HealthFirst; New York (NY); On-site; USD 83,000 - 120,000; Full time

Job summary

Healthfirst is seeking a Clinical Quality Manager to lead quality initiatives focused on HEDIS, QARR, and Medicare Advantage Star measures. You will work with providers, members, and internal teams to improve care quality and monitoring progress.

The role requires an associate degree with travel across the NYC metro area; a bachelor’s degree and a clinical license are preferred, along with HEDIS experience in Medicaid and Medicare. Strong analytical and communication skills are essential.

Qualifications

• Associates degree required; travel in NYC metro area.
• Clinical license preferred: LPN, RN, LMSW or LCSW.
• HEDIS review experience for Medicaid and Medicare.
• Medical record review experience with HEDIS/QARR in managed care.
• Strong presentation and analytical skills.
• Intermediate MS Word, Excel and PowerPoint.
• Compliance & Regulatory responsibilities as noted above.

Responsibilities

• Interact with hospitals, providers, and members to improve quality of care and monitor progress.
• Review billing codes, medical records, and claims submission processes for accuracy.
• Attend initiative meetings involving targeted providers and measures.
• Conduct on-site provider visits and educate on coding practices and chart documentation.
• Collaborate with departments to maximize outreach for preventive services and chronic disease management.
• Assist in writing member/provider articles on HEDIS, QARR and Medicare Advantage.

Skills

HEDIS knowledge

Data analysis

Presentation skills

Relationship management

Analytical skills

Education

Associate’s degree

Bachelor’s degree

Clinical license: LPN/RN/LMSW/LCSW

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

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.

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.