Quality Interventions Nurse

• Drive HealthCare Partners (HCP) providers’ quality performance as it relates to clinical documentation, coding, and gap closure for HEDIS, CMS Star, and QARR measures, with a focus on improving quality scores.
• Plan, schedule, and conduct field visits to provider offices independently to retrieve records, deliver education, and support gap closure; report visit outcomes and follow-up actions to leadership.
• Conduct outreach to members and providers to close gaps in care, and support other quality measures as required, including medication adherence.
• Build and maintain strong relationships with providers and office staff; educate them on quality measures, relevant clinical guidelines, and appropriate documentation techniques.
• Access provider EMRs remotely to review and obtain medical records, following HIPAA, minimum-necessary standards, and HCP access protocols; exercise a high degree of care and accuracy with every record accessed. Build trust with PCP offices to input alerts for gaps requiring action and ensure data is updated timely and accurately.
• Review and abstract medical data from diverse sources including, but not limited to, inpatient and outpatient medical records and immunization registries for clinical data elements specific to HEDIS/QARR measure specifications.
• Document all medical record abstractions accurately into electronic record keeping systems and maintain documentation retrieval, abstraction, and accuracy standards.
• Comply with HCP procedures for scheduling, requesting, and reviewing records on-site, via EMR, and by phone, email, or fax.
• Manage own schedule of remote record reviews, field visits, and outreach, and adjust quickly as priorities shift.
• Perform root cause analysis for coding/documentation inaccuracies; create work plans per provider to measure office progress as needed.
• Serve as subject matter expert on quality measures, HEDIS/QARR/Stars technical specifications, and clinical guidelines for the Quality team and providers.
• Stay current on annual HEDIS/QARR/Stars specification updates, regulatory changes, and industry trends, and understand the clinical rationale behind each quality measure.
• Develop and deliver trainings and briefings for the Quality department and other impacted staff on quality, HEDIS, and industry updates.
• Collaborate with Provider Network, Quality Intervention Coordinators, pharmacists, and other departments to maximize member outreach for preventive services and chronic disease management.
• Work with complex data sets, such as gap lists, claims, and performance reports, to prioritize providers, members, and records for review.
• Assist in developing member and/or provider educational materials in relation to HEDIS, Medicare Stars, QARR, and/or other health communications.
• Respond promptly to requests from leadership, providers, and team members, and take on assignments and HCP initiatives with minimal direction.
• Perform other duties or responsibilities as necessary or assigned.

• Minimum of 2 years of HEDIS medical record abstraction experience in both Medicare and Medicaid is required
• 2+ years of provider engagement experience, preferred Knowledge of HEDIS/QARR requirements for Medicaid line of business including medical record review and/or reporting processes, preferred

• Active New York State RN or LPN license in good standing
• Valid driver’s license in good standing and access to reliable transportation for field visits

• Passionate about quality and focused on outcomes, with a drive to improve quality scores
• Self-starter and self-motivated; able to take a request from management and determine the approach and next steps without needing a detailed outline
• Solution-focused, comes to the table with proposed solutions, not just problems
• Responsive and dependable with providers, leadership, and colleagues
• Collaborative team player who works well across departments
• Takes initiative to stay on top of quality measure updates and industry trends

• Excellent verbal and written communication and presentation skills.
• Superior interpersonal skills with the ability to build and maintain positive relationships with providers, office staff, and team members across the organization, and to influence with and without formal authority to drive performance outcomes.
• Expert knowledge of HEDIS, CMS Star, and QARR measures and technical specifications.
• Strong attention to detail and accuracy, particularly when accessing and abstracting medical records.
• Comfortable working with large, complex data sets and translating findings into action.
• Ability to work in a multidisciplinary team in a fast-paced environment with frequently changing priorities.
• Strong organizational and time management skills to manage an independent schedule of remote and field work.
• Exceptional problem-solving and critical thinking skills, and the ability to learn new skills quickly.
• Must have a working knowledge of MS Excel, Word, and PowerPoint.
• Experience working in electronic medical record (EMR) systems is a plus.

Department: Quality
This is a non-management position
This is a full time position