Clinical Quality Coordinator, Intermediate

Your Role

The Clinical Quality team oversees and is responsible of HEDIS medical record review, pursuit, and overall HEDIS submission. The Supervisor of Quality Clinical Quality Coordinator will report to the Manager or Supervisor of the HEDIS Outreach Team. In this role you will be responsible for conducting provider outreach during the HEDIS season for medical record pursuit and retrieval. Also, participation in Quality initiatives involving member outreach for care gap closure. Responsible for maintaining high productivity and standard work. 

Your Work

In this role, you will:

• Initiate outbound calls to members and providers to collect information and provide care coordination assistance in obtaining services (schedule appointments, provider appointment reminders, coordinate transportation, etc.)

• Educate members on missing care gaps and provide encouragement to obtain missing service.

• Request medical records from PCP/Specialists by fax, remote EMR access or scheduled site visits as needed 

• Manage and maintain HEDIS files and medical records 

• Provide administrative support, including generating correspondence, organize mass mailings, coordinator schedules and training 

• Continued development of understanding of HEDIS hybrid measures and medical record requirements for HEDIS compliance 

• Research member claims and encounters to identify accurate pursuit information for medical record retrieval
• Review medical records and identify elements for compliance
• Create and maintain detailed logs of member and provider interactions 
• Ability to de-escalate situations
• Assist in onboarding contingent workforce for HEDIS and outreach projects
• EMR and vendor portal medical record retrieval
• Developing understanding of HEDIS pursuit processes relative to pursuit systems and tracking processes
• Developing understanding of outreach and pursuit project intake procedures, schedules, and reporting requirements
• Ability to work independently in a fast-paced environment with minimal errors

Your Knowledge and Experience

• Requires a high school diploma or equivalent
• Requires basic job knowledge of systems and procedures obtained through prior work experience or education.
• Typically, requires minimum of 3 years of experience. May require vocational or technical education in addition to prior work experience.
• Required communication and interpersonal skills
• Must be organized with the ability to keep accurate notes and records
• Required customer service experience
• Required HEDIS knowledge
• Required critical thinking skills

• Required knowledge of computer applications including Microsoft Word, PowerPoint and Excel. Internet knowledge with the ability to complete searches