Quality HEDIS-STAR Nurse - JHP

Jefferson Health; Philadelphia (Philadelphia County); On-site; USD 80,000 - 120,000; Full time

Benefits offered by this job

Medical insurance

Tuition assistance

Retirement plans

Job summary

Health Partners Plans, Inc. in Philadelphia seeks a Clinical STARS-HEDIS Specialist to support Quality Management, close care gaps, and drive performance for Stars, HEDIS, NCQA Accreditation, CAHPS, and PCMH.

You will perform provider outreach and medical record reviews across departments to improve quality outcomes. The role requires a Nursing degree with PA RN licensure and 3+ years in managed care or quality review, plus strong MS Office and EMR skills.

Qualifications

• Bachelor's degree in nursing and active RN license required in PA.
• 3 years of managed care, clinical case management or quality review experience.
• Proficient in Microsoft Office, SharePoint and Teams.
• Knowledge of clinical terminology and standards for abstracting care gaps.

Responsibilities

• Conduct provider outreach calls to complete clinical/quality assessments related to HEDIS/Stars.
• Perform medical record reviews to identify care gaps and report to PCPs on adherence and regulatory objectives.
• Assist Quality Management with chart reviews during HEDIS season and quality initiatives.
• Collaborate with HEDIS, Care Management, UM, enrollment, member services and others to resolve quality concerns.
• Document findings in Care Management systems, Access, Excel and other tools as required.

Skills

Clinical case management

Quality improvement

Provider outreach

MS Office

Communication skills

Education

Bachelor's Degree in Nursing

RN - PA license

Tools

EMR systems

SharePoint & Teams

Job description

Number of Positions In Requisition
1
Job Details
The Clinical STARS-HEDIS Specialist will provide clinical support to the Quality Management department as well as other areas throughout the organization in order to assist with Care Gap Closure. The Specialist will contribute to quality initiatives and activities, conducting provider outreach calls, and medical record reviews to help drive HPP's performance as it relates to Stars, HEDIS, NCQA Accreditation, CAHPS, and Patient-Centered Medical Home (PCMH).

Job Description

Summary

The Clinical STARS-HEDIS Specialist will provide clinical support to the Quality Management department as well as other areas throughout the organization in order to assist with Care Gap Closure. The Specialist will contribute to quality initiatives and activities, conducting provider outreach calls, and medical record reviews to help drive HPP's performance as it relates to Stars, HEDIS, NCQA Accreditation, CAHPS, and Patient-Centered Medical Home (PCMH).

Job Duties

• Conduct Provider outreach calls to complete clinical/quality assessments related to HEDIS and Stars, including pain and functional assessments
• Conduct quality medical record reviews to ensure a continuum of care management effectiveness and to report to the PCP potential gaps and adherence issues against clinical, HEDIS, Stars, Credentialing and Re-credentialing, and other regulatory objectives
• Assist the Quality Management team by conducting medical chart reviews or overreads during the HEDIS season
• Identify quality-related issues and recommend potential solutions
• Identify and share best practices, a significant contribution to process improvement initiatives, and actively support these initiatives
• Collaborate with internal departments (such as HEDIS, Care Management, UM, enrollment, member services, and Complaints and Grievances) to facilitate resolutions for potential quality issues and concerns
• Document appropriately in the Care Management system, Access, Excel files, and other areas, as needed, by departmental requirements
• Operate CIC and telephone systems effectively and efficiently, following established protocols for security, transfer, and information exchange
• Other duties as assigned

Minimum Qualifications

• Bachelor's Degree in Nursing
• 3 years experience in managed care, clinical case management or quality review required
• Proficient use of Microsoft Office, SharePoint and Teams required
• Knowledge of clinical case management, medical terminology required
• Ability to read and interpret standards to perform certain functions of the job required
• Exceptional presentation, oral and written communication, interpersonal, problem solving, multitasking and time management skills required
• Exceptional customer service skills required
• Ability to work independently and as part of a team required
• RN - Licensed Registered Nurse_PA - State of Pennsylvania
• DL - Driver's License_PA - State of Pennsylvania

Preferred Qualifications

• Experience with various electronic medical records (EMRs) preferred
• Ability to organize and manage multiple priorities

Physical Demands

Lift and carry 25 lbs. frequent sitting/standing, frequent keyboard use, *patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.

Job Description Disclaimer

This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Health Partners Plans, Inc.

Primary Location Address

1101 Market, Philadelphia, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University , home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health , nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.

Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time(including per diem colleagues, adjunct faculty, and Jeff Temps ), have access to medical (including prescription) insurance.

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