QI SPECIALIST II (HEDIS)

Location: Irving, TX
Duration: 3+ Months (Temp to Perm)

Duration:
Possibility to be extended beyond initial 90 days and if the agent has great attendance and performance. In addition, they will be evaluated for a potential perm role.

Bilingual is a plus but not a must.
There is travel:
They will be visiting local provider offices to pick up medical records or performing audits on those offices.
All candidates need a valid unrestricted driver’s license.

Establishes and fosters a healthy working relationship between community physician practice. Educates providers and supports provider practice sites in regards to the

National Committee for Quality Assurance (NCQA) HEDIS measures. Provides education for

HEDIS measures; reviews charts for appropriate medical record documentation and appropriate
coding. Candidate assists in resolving deficiencies impacting plan compliance to meeting State and
Federal standards for HEDIS/STAR Measures. Acts as a resource for the market on HEDIS
measures, appropriate medical record documentation and appropriate coding. Candidate supports the
development and implementation of quality improvement interventions and reviews in relation to
plan providers.

Essential Functions:
• Advises and educates Provider practices in appropriate HEDIS measures, medical record
documentation guidelines and HEDIS ICD-9/10 CPT coding in accordance with NCQA
requirements.
• Collects, summarizes and trends provider performance data to identify and strategize opportunities
for provider improvement.
• Collaborates with Provider Relations to improve provider performance in areas of Quality, Risk
Adjustment, Operations (claims and encounters).
• Delivers provider specific metrics and coach providers on gap closing opportunities.
• Develops, enhances and maintains provider clinical relationship across product lines.
• Leads and/or supports collaborative business partnerships, elicit client understanding and insight to
advise and make recommendations.
• Partners with physicians/physician staff to find ways to explore new ways to encourage member
clinical participation in wellness and education.
• Provides resources and educational opportunities to provider and staff.
• Captures concerns/issues in action plans as agreed upon by Provider.
• Documents action plans and details of visits and outcomes; reports critical incidents and information
regarding quality of care issues.
• Communicates with external data sources as needed to gather data necessary to measure identified
outcomes.
• Provides communication such as newsletter articles, member education, outreach interventions and
provider education.
• Coordinates and host clinic and event days to address provider/SDA missing services.
• Supports quality improvement program studies and HEDIS as needed, requesting records from
providers, maintaining databases, and researching to identify members' provider encounter history.
• Ensures that documentation produced and/or processed complies with state regulations and/or
accrediting body requirements.
• Participates in and represents plan at community, health department, collaborative and other
organizational meetings focusing on quality improvement, member education, and disparity
programs, as assigned.
• Supports QI program studies and HEDIS as needed, requesting records from providers, maintaining
databases and researching to identify member’s provider history.
• Ensures accuracy in medical records for data collection, data entry and reporting. Enters
documentation of findings in identified databases.
• Performs other duties as assigned.
Candidate Education:
• Bachelor's Degree in Healthcare, Public Health, Nursing, Psychology, Health Administration, Social
Work or related field is required.

Candidate Experience:
• 2 years of experience in directly related HEDIS medical record review and/or Quality Improvement
with experience in data and chart reviews to provide consultation and education to providers and
provider staff is required
• Care experience is preferred
Candidate Skills:
• Demonstrated interpersonal/verbal communication skills
• Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
• Ability to multi-task
• Ability to work in a fast paced environment with changing priorities
• Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw
valid conclusions
• Ability to implement process improvements
• Ability to effectively present information and respond to questions from families, members, and
providers
• Ability to influence internal and external constituents
• Demonstrated analytical skills
• Ability to analyze and interpret financial data in order to coordinate the preparation of financial
records
• Understanding of data analysis and continuous quality improvement process
Licenses and Certifications:
A license in one of the following is required:

• Licensed Practical Nurse (LPN)
• Licensed Registered Nurse (RN)

Technical Skills:
• Microsoft Excel is required
• Microsoft PowerPoint is required
• Microsoft Outlook is required

All your information will be kept confidential according to EEO guidelines.