Quality HEDIS-STAR Nurse - JHP

Jefferson Health; Philadelphia (Philadelphia County); On-site; USD 90,000 - 120,000; Full time

Job summary

Jefferson Health is seeking a Clinical STARS-HEDIS Specialist to support the Quality Management department and drive care gap closure. The role involves provider outreach, medical record reviews, and collaboration across Care Management, HEDIS, UM, enrollment, and member services to improve Stars, NCQA Accreditation, CAHPS, and PCMH outcomes.

Ideal candidates will have a Nursing degree, 3+ years in managed care or quality review, and strong communication, problem solving, and teamwork skills.

Qualifications

• Bachelor’s degree in Nursing required.
• Minimum 3 years in managed care, clinical case management, or quality review.
• Proficient with Microsoft Office, SharePoint, and Teams.
• Knowledge of clinical case management and medical terminology.
• Ability to read and interpret standards for job functions.
• Excellent presentation, oral/written communication, interpersonal, problem solving, multitasking and time management.
• Exceptional customer service skills.
• Ability to work independently and in a team.
• RN license in PA, PA Driver's License.

Responsibilities

• Conduct provider outreach calls to complete clinical/quality assessments related to HEDIS and Stars, including pain and functional assessments.
• Perform quality medical record reviews to ensure care management effectiveness and report gaps to PCP.
• Assist Quality Management with chart reviews/overreads during HEDIS season.
• Identify quality issues and recommend potential solutions.
• Share best practices and support process improvement initiatives.
• Collaborate with HEDIS, Care Management, UM, enrollment, member services, and Grievances to resolve quality concerns.
• Document in Care Management systems, Access, Excel per requirements.
• Operate CIC and telephone systems per security and information exchange protocols.
• Other duties as assigned.

Skills

RN license

PA license

Driver's license

Microsoft Office

SharePoint

Teams

Clinical knowledge

Communication

Independent & team work

Education

Bachelor’s Degree in Nursing

Tools

Microsoft Office

SharePoint

Teams

Job description

Number of Positions In Requisition1Job DetailsThe 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 DescriptionSummaryThe 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 DutiesConduct Provider outreach calls to complete clinical/quality assessments related to HEDIS and Stars, including pain and functional assessmentsConduct 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 objectivesAssist the Quality Management team by conducting medical chart reviews or overreads during the HEDIS seasonIdentify quality-related issues and recommend potential solutionsIdentify and share best practices, a significant contribution to process improvement initiatives, and actively support these initiativesCollaborate with internal departments (such as HEDIS, Care Management, UM, enrollment, member services, and Complaints and Grievances) to facilitate resolutions for potential quality issues and concernsDocument appropriately in the Care Management system, Access, Excel files, and other areas, as needed, by departmental requirementsOperate CIC and telephone systems effectively and efficiently, following established protocols for security, transfer, and information exchangeOther duties as assignedMinimum QualificationsBachelor’s Degree in Nursing3 years experience in managed care, clinical case management or quality review requiredProficient use of Microsoft Office, SharePoint and Teams requiredKnowledge of clinical case management, medical terminology requiredAbility to read and interpret standards to perform certain functions of the job requiredExceptional presentation, oral and written communication, interpersonal, problem solving, multitasking and time management skills requiredExceptional customer service skills requiredAbility to work independently and as part of a team requiredRN - Licensed Registered Nurse_PA - State of PennsylvaniaDL - Driver's License_PA - State of PennsylvaniaPreferred QualificationsExperience with various electronic medical records (EMRs) preferredAbility to organize and manage multiple prioritiesPhysical DemandsLift 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 ShiftWorkday Day (United States of America)Worker Sub TypeRegularEmployee EntityHealth Partners Plans, Inc.Primary Location Address1101 Market, Philadelphia, Pennsylvania, United States of AmericaNationally 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.BenefitsJefferson 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.