Quality HEDIS-STAR Nurse - JHP

Number of Positions In Requisition
1


Job Details
The Clinical STARS-HEDIS Specialist will provide clinical support to the Quality Management department as well as other areas throughout the organization in order to assist with Care Gap Closure. The Specialist will contribute to quality initiatives and activities, conducting provider outreach calls, and medical record reviews to help drive HPP's performance as it relates to Stars, HEDIS, NCQA Accreditation, CAHPS, and Patient-Centered Medical Home (PCMH).
Job Description
Summary
The Clinical STARS-HEDIS Specialist will provide clinical support to the Quality Management department as well as other areas throughout the organization in order to assist with Care Gap Closure. The Specialist will contribute to quality initiatives and activities, conducting provider outreach calls, and medical record reviews to help drive HPP's performance as it relates to Stars, HEDIS, NCQA Accreditation, CAHPS, and Patient-Centered Medical Home (PCMH).
Job Duties
Conduct Provider outreach calls to complete clinical/quality assessments related to HEDIS and Stars, including pain and functional assessments
Conduct quality medical record reviews to ensure a continuum of care management effectiveness and to report to the PCP potential gaps and adherence issues against clinical, HEDIS, Stars, Credentialing and Re-credentialing, and other regulatory objectives
Assist the Quality Management team by conducting medical chart reviews or overreads during the HEDIS season
Identify quality-related issues and recommend potential solutions
Identify and share best practices, a significant contribution to process improvement initiatives, and actively support these initiatives
Collaborate with internal departments (such as HEDIS, Care Management, UM, enrollment, member services, and Complaints and Grievances) to facilitate resolutions for potential quality issues and concerns
Document appropriately in the Care Management system, Access, Excel files, and other areas, as needed, by departmental requirements
Operate CIC and telephone systems effectively and efficiently, following established protocols for security, transfer, and information exchange
Other duties as assigned
Minimum Qualifications
Bachelor’s Degree in Nursing
3 years experience in managed care, clinical case management or quality review required
Proficient use of Microsoft Office, SharePoint and Teams required
Knowledge of clinical case management, medical terminology required
Ability to read and interpret standards to perform certain functions of the job required
Exceptional presentation, oral and written communication, interpersonal, problem solving, multitasking and time management skills required
Exceptional customer service skills required
Ability to work independently and as part of a team required
RN - Licensed Registered Nurse_PA - State of Pennsylvania
DL - Driver's License_PA - State of Pennsylvania
Preferred Qualifications
Experience with various electronic medical records (EMRs) preferred
Ability to organize and manage multiple priorities
Physical Demands
Lift and carry 25 lbs. frequent sitting/standing, frequent keyboard use, *patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.
Job Description Disclaimer: This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.
Work Shift
Workday Day (United States of America)
Worker Sub Type
Regular
Employee Entity
Health Partners Plans, Inc.
Primary Location Address
1101 Market, Philadelphia, Pennsylvania, United States of America
Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.
Jefferson is committed to providing equal educa­tional and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gend