Role Overview: This position involves managing quality improvement initiatives by reviewing medical records, supporting HEDIS and prenatal/postpartum measures, and collaborating with healthcare providers to enhance care outcomes.
- Responsibilities: Conduct retrospective medical record reviews, ensure compliance with regulatory standards (NCQA, CMS), and document data accurately.
- Manage assigned member caseloads, execute interventions for non-compliance, and track progress using quality reports.
- Educate and collaborate with primary care providers and staff on quality standards, preventive health guidelines, and care coordination.
- Participate in member outreach, support case management referrals, and assist in process improvements.
- Identify potential fraud or quality issues, and contribute to quality enhancement strategies.
Qualifications & Skills: Must have at least three years of LPN experience, familiarity with medical record review, regulatory standards, and computer literacy. Ability to work independently across multiple locations and document data accurately is essential.
Key Attributes: Strong communication, collaboration, attention to detail, and commitment to quality healthcare are vital for success in this role.