Provider Clinical Consultant, Quality and Risk Adjustment

Workforce Classification:

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In partnership with Premera Medical Directors and Provider Network Executives, the Provider Clinical Consultant (PCC), Quality and Risk Adjustment works directly with providers to evaluate, recommend, and monitor the implementation of better practice processes for improved outcomes that focus on keeping Premera members healthy.

The Provider Clinical Consultant will work directly and build relationships with care providers, proactively identify performance improvement opportunities through data analysis and discussion with subject matter experts, consult with providers to assess and recommend processes and procedures to ensure high quality and timely care to our members, recommend ways to optimize IT tool use (e.g.; electronic health records, population health management software, etc.), and ensure adequate training is available for documentation and coding best practices for HEDIS and risk adjustment. This role will have a positive impact on our clinical quality and coding quality work.

This position will work in the field and remotely with clinicians, administrators, coders/billers, and other operational team members, and will maintain bi-weekly/monthly operational level communication for support and performance reporting.

What you’ll do:

• Build and maintain strong professional relationships with provider organizations, including administrative and clinical staff as well as providers. Utilize consultative skills to develop and execute strategies to influence provider behavior. Be able to travel frequently across the assigned territory for in-person provider support.

• Understand and clearly communicate concepts related to risk adjustment, documentation, and coding best practices.

• Understand and clearly communicate nationally established measures to include NCQA/HEDIS and be able to speak to each measure’s technical specifications and reporting requirements.

• Understand and clearly convey relevant utilization management best practices, Premera medical policies, and pharmacy/pharmacy benefit manager utilization management activities.

• Consult with Medical Directors, Provider Strategy and Solutions, Actuarial, Corporate Data and Analytics and other key Premera stakeholders to support provider capability to provide quality and timely care to members. Function well within the triad that includes medical director and provider network executive while also working independently.

• Assess configuration and use of provider tools that support population health and care management (EMR, billing and scheduling software, population health tools, etc.) and make recommendations for enhancements to configuration, workflows, and/or processes to support better care for Premera members.

• Understand how to use established and signed risk-based and shared savings contracts and performance incentives t