Clinical Quality Manager

The Clinical Quality Manager with members and providers to ensure members receive appropriate services. This role emphasizes improving the quality of care with a focus on HEDIS, QARR and Medicare Advantage Star measures.

• Interacts with hospitals, providers, and members to improve quality of care, monitor progress, and recommend changes
• Reviews billing codes, medical records, and claims submission process to ensure accuracy
• Attends and facilitates any initiative meetings (studies, partnerships) that involve targeted providers and/or measures.
• Completes on-site visits on a regular basis to implement the work plan and to conduct provider education sessions regarding appropriate coding practices and chart documentation.
• Collaborates with other departments to maximize member outreach for preventive services and chronic disease management.
• Assists in writing member and/or provider articles in relation to HEDIS, QARR, Medicare Advantage and/or health promotions for HF newsletter.
• Supports regulatory affairs, as deemed necessary by management.
• Documents all relevant interactions in appropriate systems
• Additional duties as assigned

Minimum Qualifications:

• Associate’s degree from an accredited institution
• Ability to travel around the NYC metro area

Preferred Qualifications:

• Bachelor’s Degree from an accredited institution
• Clinical license: LPN, RN, LMSW or LCSW
• Multiple years of HEDIS review experience for both Medicaid and Medicare lines of business
• Medical record review experience directly working on HEDIS/QARR in a managed care setting
• Good presentation, relationship management, and analytical skills
• Intermediate MS Word, Excel, and PowerPoint
• Compliance & Regulatory Responsibilities: Noted above

License/Certification: N/A

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $83,100 - $120,360

• All Other Locations (within approved locations): $73,400 - $108,160

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

• The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

73400-108160