Government Programs Clinical Quality, HEDIS Specialist

Job not on LinkedIn

🔥 5 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 12%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Arkansas Blue Cross and Blue Shield

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1948

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Arkansas Blue Cross and Blue Shield is a health insurance provider licensed to offer health plans in all 75 counties of Arkansas. The company offers a wide range of insurance products including individual and family plans, Medicare and Medigap plans, dental and vision plans, as well as health plans for travelers and employer group plans. They provide members with personalized services such as health management through the Blueprint Portal, where users can manage their health plan, review claims, find healthcare providers, and estimate treatment costs. Arkansas Blue Cross and Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association.

📋 Description

• Conduct telephonic care coordination and health coaching for members and families • Identify preventive care, disease management, medication adherence, and other healthcare intervention opportunities • Access appropriate health-related services and coordinate care with members, pharmacies, physicians, and providers • Retrieve, abstract, and overread clinical medical records for HEDIS audit activities and quality-gap initiatives • Ensure medical record review accuracy and compliance with CMS quality initiative guidelines • Develop member work and progress plans based on member interactions and insights • Help members schedule appointments and navigate the healthcare delivery system • Identify and triage members to appropriate healthcare resources and resolve barriers to care • Measure, analyze, and report HEDIS quality initiative results • Create tools to capture and report information on member and provider quality-gap trends • Create member and practitioner educational materials • Assist with quality improvement initiatives • Build relationships and serve as liaison and advocate among members, providers, health departments, and community organizations • Perform provider outreach, including distributing gap reports and retrieving medical records • Monitor gap closures and improvement activities with Stars Member Outreach Specialists, Stars Improvement Nurses, and health plan staff • Perform other activities and projects as directed by Clinical Quality & HEDIS leadership

🎯 Requirements

• Bachelor’s degree in Health Science, Public Health, Psychology, Social Work, Health Administration, or another healthcare-related field; five years of related experience may substitute for the degree • Associate degree in a listed field plus two additional years of related experience may satisfy the education requirement • Minimum three years of work experience in direct patient care, social work, quality improvement, health coaching, clinical or healthcare service quality improvement, or health data analytics • Minimum one year of experience in Medicare Advantage • Experience working directly with patients • Valid driver’s license • Must successfully pass the Inter-Rater Reliability (IRR) test within 90 days of hire and/or assignment • Must achieve a passing score of 95% on the IRR test • Knowledge of complex healthcare systems and ability to advocate for member needs • Understanding of culturally diverse populations and ability to evaluate literacy needs • Proficiency in Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook • Ability to travel within the designated service area as necessary • Ability to protect confidential healthcare information and comply with applicable laws, policies, rules, and regulations • Ability to assess needs and design, develop, and implement goal-oriented care plans • Ability to identify problems, collect data, establish facts, and draw valid conclusions • Active RN, LPN, LBSW, or CPht licensure/certification preferred • CPC certification preferred but not required • Experience as a health navigator, patient navigator, patient advocate, care advocate, or health coach strongly preferred • Strong understanding of HEDIS measures and technical specifications preferred • Medical record abstraction, claims coding, education, and training experience preferred • Bilingual ability a plus

🏖️ Benefits

• Regular employment • Remote work arrangement • Campus travel within walking distance of the primary work assignment • Professional development and training related to HEDIS abstraction, quality improvement, and care coordination