The Quality Improvement Analyst serves as an expert resource for the organization on Medicare Advantage Star Ratings and associated quality measures. Responsibilities include active involvement in annual plan development, implementation, and monitoring. Serves as a subject matter expert and assumes primary accountability for MDX Hawai‘i’s quality improvement initiatives, focusing on initiatives related to Star Ratings. Develops and oversees plans to achieve a Five Star Rating for HMO and PPO Medicare Advantage Plans through coordination of efforts with internal and external stakeholders. Develops, implements, and monitors Medicare required Quality programs and activities. Develops, implements, and assists with audits as needed to gather data and monitor status of quality initiatives. Completes data analysis to guide strategic planning and provider, member, and market specific interventions, where applicable. This position will have the opportunity and responsibility to create project plans as well as collaborate with many other resources to improve processes. This role will be responsible to research opportunities for improvement. Tools utilized will include the electronic and paper health record, claims system, clinical informatics reports, national guidelines, NCQA standards, HEDIS specifications, CMS regulations and other applicable resources.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Conducts studies and analyzes data to evaluate MDX Hawaii’s performance in quality improvement, with duties including but not limited to:
- Performing computer-based statistical analysis of data related to the Quality Improvement (QI) program;
- Monitoring and ensuring the validity of data;
- Evaluating reports for accuracy of data;
- Performing analysis to determine statistically significant trends in the data compared to industry standards and recognized benchmarks;
- Providing technical expertise in statistical analysis to staff of HCQ and external agencies as necessary;
- Creating process documentation for Star Rating and Quality program activities; and
- Utilizing MDX Hawaii’s data systems to generate, manipulate and analyze data;
Analyzes, develops and implements improvement activities to increase compliance rates as measured by nationally standardized benchmarks and definitions, with duties including but not limited to:
- Identifying preventive care areas with declining or plateauing compliance rates over time, including root cause analysis for contributing factors;
- Developing and implementing interventions, including provider level report cards, educational programs and outreach strategies for providers and members to facilitate compliance and competency with HEDIS guidelines;
- Working with report writers to validate and troubleshoot data in HCC manager, Axis and any other systems.
- Tracking Quality data issues and recommend solutions
- Evaluating and reporting compliance rates on a quarterly basis;
- Working in collaboration with internal DMO and IT staff and MDX Long Beach developers as needed and build teams to implement enhancements.
- Responding to inquiries from and communicates with physicians, coders, and other healthcare team members to facilitate comprehensive medical record documentation to accurately reflect services provided to the patient.
- Working with provider offices directly to increase compliance rates and practice improvement; and
- Requesting information from physician and other providers’ offices.
Assists with HEDIS reporting with duties including but not limited to:
- Coordinating and submitting samples to the health plan to ensure quality data;
- Maintaining HEDIS member exclusion data;
- Maintaining a problem log of software issues;
- Training providers and staff regarding how to use various programs;
- Working with supplemental data sources such as immunization registries and lab vendors;
- Presents updates and summaries to executive leadership, staff, and other audiences as required.
- Works closely with the Medical Director and other team members to plan and develop clinical quality improvement projects and member and provider engagement activities.
- Coordinates the implementation with the HCQ department, Provider Network Operations and other partners/vendors.
- Integrates Stars activities with HCC risk adjustment initiatives to optimize care improvement opportunities with revenue management.
- Develops training materials and education strategies based on QA results to promote complete and accurate documentation of and correct negative trends.
- Conducts coaching and training as appropriate for physicians, NPs, and other staff to improve the quality of the documentation, collection and coding of members’ health data.
- Creates performance improvement plan as needed. Participates in liaison meetings between MDX Hawai‘i functional areas and serves as a primary consultant to billing and claims as needed to assist with coding duties.
- Plans and coordinates provider meetings, seminar and direct mail activities as assigned.
- Leads and participates in special projects, as directed.
- Performs other duties, as assigned.
MARGINAL DUTIES AND RESPONSIBILITIES
Support the Plan’s Quality Monitoring Program; participate in ongoing clinical quality improvement activities as it relates to programs and processes, studies, projects and medial record reviews. Address the needs of internal and external customers; including co-workers, internal departments, Members, Providers and Vendors. Provides cross-training to other staff as well as cross-train in other functions as requested. Attend workshops and seminars as directed to improve knowledge. Participate in various task force and committee projects, as requested.
EDUCATION AND/OR EXPERIENCE:
High School Graduate Required Five years in managed healthcare field or academic equivalent. Requires experience with quality improvements, requirements, and regulations or related fields (i.e., NCQA, Medicare, Medicaid, etc.). Willingness to take full ownership for program success and instill accountability in cross functional teams to achieve corporate goals.
TYPICAL WORKING CONDITIONS:
Incumbent will work in the office setting, provider office settings and other locations where demonstrations, evaluations and/or training sessions are performed. Requires travel via own automobile throughout O‘ahu. Required day and/or overnight travel to Neighbor Islands. Requirements set forth in the specific contract for the site may include working flexible hours including evenings, nights and weekends.
LICENSES, CERTIFICATIONS, REGISTRATIONS:
Current/valid Hawai‘i Driver’s License. Proof of Hawai‘i No-Fault Auto Insurance. Clean driving record as evidenced by a recent driver’s abstract (to be provided by the employee).