Candidate must live in one of the following counties: Wayne, Macomb, Monroe, Lenawee, or Washtenaw. Preferably Wayne county.
- Establishes and fosters a healthy working relationship between community physician and small provider practices and WellCare.
- Educates providers and supports provider practice sites in regards to the National Committee for Quality Assurance (NCQA) HEDIS measures.
- Provides education for HEDIS measures, appropriate medical record documentation and appropriate coding.
- Assists in resolving deficiencies impacting plan compliance to meet State and Federal standards for HEDIS.
- Under general guidance form Senior Quality Practice Advisors and management, educates community physician and small provider practices in appropriate HEDIS measures, medical record documentation guidelines and HEDIS ICD-9/10 CPT coding in accordance with NCQA requirements.
- Collects, summarizes and trends provider performance data to identify and strategize opportunities for provider improvement.
- Collaborates with Provider Relations to improve provider performance in areas of Quality, Risk Adjustment and Operations (claims and encounters).
- Assists in delivering provider specific metrics and coaches providers on gap closing opportunities.
- Assists in identifying specific practice needs where WellCare can provide support.
- Partners with physicians/physician staff to find ways to encourage member clinical participation in wellness and education.
- Provides resources and educational opportunities to provider and staff.
- Captures concerns and issues in action plans as agreed upon with provider.
- Documents action plans and details of visits and outcomes. Reports critical incidents and information regarding quality of care issues.
- Communicates with external data sources as needed to gather data necessary to measure identified outcomes.
- Provides communication such as newsletter articles, member education, outreach interventions and provider education.
- Supports quality improvement HEDIS and program studies as needed, requesting records from providers, maintaining databases, and researching to identify members' provider encounter history.
- Ensures that documentation produced and/or processed complies with state regulations and/or accrediting body requirements.
- Ensures assigned contract/regulatory report content is accurate and that submission adheres to deadline.
- Enter documentation of findings in identified databases and ensure accuracy in medical records for data collection, DE and reporting.
- Performs other duties as assigned.
Required A Bachelor's Degree in Healthcare, Public Health, Nursing, Psychology, Health Administration, Social Work or related field. Prefer a Master's Degree in Healthcare, Public Health, Nursing, Psychology, Health Administration, Social Work or related field. Required 1+ year of experience in related HEDIS medical record review or quality improvement with experience in data and chart reviews to provide consultation and education to providers and provider staff OR 2 years medical coding or other transferable experience and skill set combination that demonstrates the ability to learn and perform the level of the position. Preferred Other Managed care experience
Licenses and Certifications: One of the following licenses is strongly preferred:
Preferred Certified Coding Specialist (CCS)
Preferred Licensed Practical Nurse (LPN)
Preferred Licensed Master Social Work (LMSW)
Preferred Licensed Vocational Nurse (LVN)
Preferred Licensed Mental Health Counselor (LMHC)
Preferred Licensed Marital and Family Therapist (LMFT)
Preferred Licensed Certified Social Worker (LCSW)
Preferred Licensed Registered Nurse (RN)
Preferred Acute Care Nurse Practitioner (APRN) (ACNP-BC)
Preferred Other Foreign trained physician/MD
Preferred Health Care Quality and Management (HCQM)
Preferred Certified Healthcare Professional (CHP)
Preferred Certified Professional in Healthcare Quality (CPHQ)
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.