• Job Description

  Req#: 1000002961
  Summary of Job
  
  Perform provider and member outreach to reconcile member records and validate data entry to support continuous quality improvement in Healthcare Effectiveness Data and Information Set (HEDIS) rates and STAR measures for the enterprise. Facilitate provider and member outreach supporting the MTM, OMW, and Medication Adherence quality measures to ensure member receipt of important clinical services to improve member health outcomes. Daily telephonic outreach to secure appointments with pharmacists and/or vendors to close gaps in care. Support efficient medical record retrieval for HEDIS medical record review and HEDIS supplemental data collection activities. Track calls for all lines of business related to the MTM, OMW, and Medication Adherence quality measures, reporting weekly completion statistics. Produce and process department mailings to members and physicians. Monitor internal mailboxes for department faxes and calls. Collaborate with internal departments in order to administer the MTM, OMW, and Medication Adherence quality measures.
  
  Responsibilities
  
  • Work closely with Clinical Pharmacist(s), Registered Nurses and Data Analyst(s) to prioritize members for outreach who fall in HEDIS measures including but not limited to Medication Adherence and OMW (Osteoporosis Management in Women who had a fracture) and the STAR measure MTM (Medication Therapy Management) Program.
  • Perform daily telephonic outreach to secure appointments with pharmacists and/or vendors to close gaps in care supporting Enterprise goals.
  • Perform daily provider and member outreach supporting the MTM, OMW, and Medication Adherence quality measures to ensure member receipt of important clinical services to improve member health outcomes.
  • Prepare and execute member and provider mailings.
  • Collaborate with providers and internal departments to ensure the receipt and correct processing of all supplemental data related to HEDIS claims and records and assist in correcting discrepancies.
  • Maintain high data integrity while adhering to HIPAA standards and protecting patient information.
  • Perform provider outreach to verify and document member's appropriate medical diagnoses and subsequent treatments both by telephone and in writing.
  • Coordinate call tracking and provide statistics to stakeholders.
  • Intake and organize data from other departments while ensuring proper compliance with all CMS regulations, policies and procedures.
  • Other duties/projects as assigned.
  
  
  Qualifications
  
  • High School Diploma (Required)
  • College Degree (Preferred)
  • Pharmacy Technician License (Preferred)
  • Minimum of 1 year direct customer service experience in a healthcare setting (Required)
  • Excellent telephonic and customer service skills (Required)
  • Experience analyzing data and building action plans based upon data outcomes (Required)
  • Personal motivation to achieve set goals (Required)
  • Flexibility and ability to adjust workflow to achieve company goals (Required)
  • Experience with or knowledge of Electronic Medical Records (Preferred)
  • Knowledge of or experience with HEDIS, STAR ratings, and/or quality improvement (Preferred)
  • Experience in a managed care health services environment (Preferred)
  • Experience in data collection, data entry and analysis (Preferred)
  • Knowledge of Excel and other analytical tools (Preferred)

• About the company

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