Role Overview: The position involves managing healthcare quality initiatives, focusing on HEDIS and prenatal/postpartum measures. The role requires collaboration with members and providers to improve care outcomes, conducting medical record reviews, and ensuring compliance with regulatory standards.
Key Responsibilities:
- Manage member caseloads to drive population health outcomes and improve quality ratings.
- Perform retrospective medical record reviews from multiple primary care sites to gather clinical data per NCQA and CMS standards.
- Document data accurately within quality databases and track member compliance reports.
- Engage with providers and members to promote preventive care, follow-up, and adherence to guidelines.
- Collaborate with practice staff to educate on quality standards and support health education initiatives.
- Participate in quality improvement projects, identify process opportunities, and assist with process modifications.
- Report quality issues or potential fraud and refer members for case management when appropriate.
- Stay current with regulatory standards through ongoing education.
Qualifications & Skills:
- At least three years of LPN experience.
- Familiarity with medical record review, regulatory standards, and computer proficiency.
- Ability to work independently across multiple sites and manage caseloads effectively.
- Strong communication, documentation, and collaboration skills.
Additional Information: The role is performed in a clinical environment, emphasizing compliance, quality improvement, and team collaboration. The position requires a nursing degree and commitment to providing high-quality healthcare services.