Job Alert: HEDIS Coordinator

You do not need to be an RN for this opportunity in QUALITY!  This role is responsible for ensuring HEDIS data accuracy and reporting, including coordinating and updating management on clinical quality metrics and HEDIS processes and results.  This will also include investigation, auditing, and process improvement opportunities. You will assist with quality improvement initiatives in the service and clinical areas.

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Position Purpose:
Perform duties to ensure HEDIS data accuracy and reporting, including investigation, auditing, and improvement opportunities.  Assist with quality improvement initiatives in the service and clinical areas.

Knowledge/Experience:
Bachelor’s degree in related field or equivalent experience.  3+ years of quality improvement or healthcare related experience.  Working knowledge of the National Committee on Quality Assurance (NCQA) HEDIS requirements preferred.

Skills/Competencies:
Knowledge Worker:  Critical Thinking/Execution, Adaptability/Flexibility, Communication/Relationship Development, Technical and Professional Knowledge

Position Responsibilities:

”    Coordinate, complete, and update management on clinical quality metrics and HEDIS processes and results
”    Establish and maintain an action plan to improve HEDIS scores
”    Implement process to request and evaluate member compliance reports for each HEDIS measure, including evaluating improvement opportunities
”    Collaborate with providers and internal departments on rate investigation and validation activities, including     maintaining all evidences, documentations, and changes
”    Manage the HEDIS project to include assignment of nurses, adherence to plan timeline, and vendor oversight for timeliness and quality
”    Conduct quality audit and maintain all data and process controls to ensure compliance

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Case Manager |RN |IL |Search

Medicaid Case Manager RN

Medicaid Case Manager RN

Join an organization that TRULY values their nurses! This is a rare opportunity for an RN with experience in UR to step into a managed care setting with plenty of room for growth. Review inpatient admissions to assure appropriate level of care and medical necessity. This will be done on site and tele phonically. Audit patient charts through on-site hospital visits, act as clinical resource to referral staff and make appropriate referrals. Educate patients and providers. Enters assessments, authorizations and reviews into the system.

Position requires an RN with min. 2 yrs clinical exp and UR exp. Current state nursing and driver’s license.

Knowledge/Experience: At least two years clinical nursing experience.

APPLY HERE

VP Compliance | AZ | Search

Growing specialty health company! Ensure regulatory compliance with state and other government agencies related to the health insurance industry, corporate and its business subsidiaries. Ensure business unit and corporate are in compliance with state and federal program regulations insurance regulations regulatory requirements for business entities and state contract requirements. Maintain and track laws and regulations contract documentations amendments and various compliance measures. Develop policies procedures and processes to comply with state law federal law contract requirements and various standards. Oversee administer and implement various compliance programs including fraud and abuse and HIPAA. Provide guidance to various departments regarding compliance issues and implementation of new compliance requirements with respect to regulatory and contract language. Conduct compliance audits develop and implement corrective action plans and report on achievement of action plans to senior management. Develop strategic relationships with state legislative policymakers and assist with the development of state legislative public policy concerning state insurance Managed Care Organization Medicare and Medicaid regulations and initiatives. Identify evaluate and analyze the impact of state legislative and regulatory issues and advise management concerning impact. Represent senior management at various committees meetings and seminars

Position requires a Bachelors degree in Public Policy Government Affairs Business Administration or related field. 5+ years of compliance program management and contract experience. Extensive knowledge of state administrative code and regulations state insurance laws and regulations including managed care regulations. Experience with state and federal government agencies accreditation bodies participating provider agreements HIPAA and Third Party Administration (TPA) laws credentialing regulations and prompt pay laws. Master’s or Law degree preferred.


APPLY HERE

Executive Recruiting Contact:
Pamela Ratz DeVille, CPC, CIR, CDR
DL: 866-371-0687 x256
PamD@MedicaidServices.net

VP Medical Management |Washington | Search

Select your own team to grow and develop! Establish and implement the strategic vision for all medical management and quality functions in WA. Review and analyze all activities, costs, operations and forecast data to determine department progress. Participate with executive committees on special studies. Administer and ensure compliance with NCQA and/or JACHO standards as determined for accreditation of the health plan. Participate in staff, departmental, committee, sub-committee, community, State and other activities, meetings and seminars. Get involved with provider education and contracting activity as appropriate.

Successful candidate will have Bachelor’s degree in nursing, or equivalent experience. 10+ years of clinical nursing, quality improvement, and management experience in a managed care setting. Thorough skills knowledge of quality improvement practices. Familiarity of medical information systems, medical claims payment process, medical terminology and coding. Familiarity of case management practices, managed care, and Medicaid programs. Familiarity of NCQA accreditation process and standards.

CLICK HERE TO APPLY

Executive Recruiting Contact:
Pamela Ratz DeVille, CPC, CIR, CDR
DL: 866-371-0687 x256
PamD@MedicaidServices.net

Sr. Clinical Systems Specialist| Informatics RN |Search

Tech-savvy RN will promote medical management processes and manage application integration throughout numerous areas of the organization to promote effective collaboration. Identify opportunities for process adjustments and redesign related to new business, new and existing programs. Formulate and manage work plans related to system or process initiatives. Direct and/or perform testing related to application upgrades and/or modifications. Maintain all aspects of the application described as clinical content. Monitor, analyze and coordinate resolution of large scale application issues related to the transfer of member and provider, and/or authorization data. Maintain MM web page for the Clinical System Management Unit. Work as a team with other RN’s performing similar work.

Bachelor’s degree in nursing, RN, 5-7 years of related experience. Project management in a clinical environment preferred. Ability to integrate nursing knowledge to enhance business optimization and application development. Ability to travel approximately 20%.

Executive Recruiting Contact:
Pamela Ratz DeVille, CPC, CIR, CDR
DL: 866-371-0687 x256
PamD@MedicaidServices.net

Apply Here