hedis measures validation manager

EmblemHealth

<div></div><div><div>Summary of Job</div><div>
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.</div><div>
Responsibilities</div><ul><li>
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.<br>
</li><li>
Perform daily telephonic outreach to secure appointments with pharmacists and/or vendors to close gaps in care supporting Enterprise goals.<br>
</li><li>
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.<br>
</li><li>
Prepare and execute member and provider mailings.<br>
</li><li>
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.<br>
</li><li>
Maintain high data integrity while adhering to HIPAA standards and protecting patient information.<br>
</li><li>
Perform provider outreach to verify and document member&rsquo;s appropriate medical diagnoses and subsequent treatments both by telephone and in writing.<br>
</li><li>
Coordinate call tracking and provide statistics to stakeholders.<br>
</li><li>
Intake and organize data from other departments while ensuring proper compliance with all CMS regulations, policies and procedures.<br>
</li><li>
Other duties/projects as assigned.</li></ul>
<div><div>Qualifications</div><ul><li>
High School Diploma (Required)<br>
</li><li>
College Degree (Preferred)<br>
</li><li>
Pharmacy Technician License (Preferred)<br>
</li><li>
Minimum of 1 year direct customer service experience in a healthcare setting (Required)<br>
</li><li>
Excellent telephonic and customer service skills (Required)<br>
</li><li>
Experience analyzing data and building action plans based upon data outcomes (Required)<br>
</li><li>
Personal motivation to achieve set goals (Required)<br>
</li><li>
Flexibility and ability to adjust workflow to achieve company goals (Required)<br>
</li><li>
Experience with or knowledge of Electronic Medical Records (Preferred)<br>
</li><li>
Knowledge of or experience with HEDIS, STAR ratings, and/or quality improvement (Preferred)<br>
</li><li>
Experience in a managed care health services environment (Preferred)<br>
</li><li>
Experience in data collection, data entry and analysis (Preferred)<br>
</li><li>
Knowledge of Excel and other analytical tools (Preferred)</li></ul>
</div><div><p>Additional Information
</p><ul><li>Requisition ID: 1000003045</li>
<li>Hiring Range: $39,960-$70,200</li></ul></div></div>

Quality Outreach Specialist - Remote

Mac Care

<p><b>Job Summary</b></p><p>We are seeking a detail-oriented <b>Clinical Data Analyst</b> with strong expertise in healthcare analytics and hands-on experience working with <b>clinical research data</b>. This role will support our <b>Value-Based Care (VBC)</b> and <b>MSSP initiatives</b>, while also contributing to the analysis and interpretation of clinical datasets from research and quality improvement programs.</p><p>The ideal candidate will transform complex healthcare and clinical research data into actionable insights to improve patient outcomes, ensure regulatory compliance, and drive data-informed decision-making.</p><p><b>Key Responsibilities</b></p><ul><li>Analyze and manage <b>CCLF, HCC, and quality data</b> for MSSP and Value-Based Care programs.</li><li>Work with <b>clinical research datasets</b> (e.g., study data, patient cohorts, outcomes data) to support research analysis and reporting.</li><li>Develop and maintain <b>interactive dashboards</b> using Power BI to track performance, clinical outcomes, and quality metrics.</li><li>Perform <b>data extraction, transformation, and cleaning</b> using Power Query and SQL.</li><li>Collaborate with <b>clinical, research, and operations teams</b> to identify high-risk populations and monitor quality measures.</li><li>Support <b>CMS reporting</b>, risk adjustment analysis, and quality improvement initiatives.</li><li>Assist in <b>clinical study data validation, reconciliation, and audit readiness</b>.</li><li>Ensure data integrity, accuracy, and compliance with <b>healthcare regulations (HIPAA, CMS guidelines)</b>.</li><li>Translate complex datasets into <b>clear insights and recommendations</b> for leadership and stakeholders.</li></ul><p><b>Requirements</b></p><ul><li>Bachelor&rsquo;s degree in <b>Computer Science, Data Analytics, Public Health, Biostatistics</b>, or a related field.</li><li><b>2&ndash;4 years of experience</b> in healthcare data analytics, <b>clinical research data analysis</b>, or value-based care programs.</li><li>Hands-on experience working with <b>clinical datasets, research data, or population health data</b>.</li></ul><p><b>Technical Skills</b></p><ul><li>Power BI (2+ years) &ndash; dashboarding and visualization</li><li>Power Query (2&ndash;3 years) &ndash; data transformation</li><li>SQL &ndash; data extraction and manipulation</li><li>Strong skills in <b>data cleaning, validation, and analysis</b></li></ul><p><b>Domain Knowledge</b></p><ul><li>Understanding of <b>CMS programs, MSSP, and HCC risk adjustment</b></li><li>Familiarity with <b>clinical research processes, datasets, and reporting standards</b></li><li>Experience with <b>EMR/EHR systems and population health tools</b></li></ul><p><b>Preferred Qualifications</b></p><ul><li>Experience supporting <b>clinical trials, registry data, or outcomes-based research</b></li><li>Knowledge of <b>study design, cohort analysis, and healthcare quality measures (e.g., HEDIS)</b></li><li>Exposure to <b>statistical tools (R, Python, or similar)</b> is a plus</li></ul><p>Job Type: Full-time</p><p>Work Location: In person</p>

Clinical Data Analyst

<p>Job Summary</p><p>We are seeking a detail-oriented <b>Clinical Data Analyst</b> with strong expertise in healthcare analytics, hands-on experience working with clinical research data, and practical experience using <b>Athena EMR/EHR systems</b>. This role will support our Value-Based Care (VBC) and MSSP initiatives, while also contributing to the analysis and interpretation of clinical datasets from research and quality improvement programs.</p><p>The ideal candidate will transform complex healthcare and clinical research data into actionable insights to improve patient outcomes, ensure regulatory compliance, and drive data-informed decision-making.</p><p>Key Responsibilities</p><ul><li>Analyze and manage CCLF, HCC, and quality data for MSSP and Value-Based Care programs.</li><li>Work with clinical research datasets (e.g., study data, patient cohorts, outcomes data) to support research analysis and reporting.</li><li>Extract, validate, and analyze patient and operational data from <b>Athena EMR</b> and other healthcare systems.</li><li>Develop and maintain interactive dashboards using Power BI to track performance, clinical outcomes, and quality metrics.</li><li>Perform data extraction, transformation, and cleaning using Power Query and SQL.</li><li>Collaborate with clinical, research, and operations teams to identify high-risk populations and monitor quality measures.</li><li>Support CMS reporting, risk adjustment analysis, and quality improvement initiatives.</li><li>Assist in clinical study data validation, reconciliation, and audit readiness.</li><li>Ensure data integrity, accuracy, and compliance with healthcare regulations (HIPAA, CMS guidelines).</li><li>Translate complex datasets into clear insights and recommendations for leadership and stakeholders.</li></ul><p>Requirements</p><ul><li>Bachelor&rsquo;s degree in Computer Science, Data Analytics, Public Health, Biostatistics, or a related field.</li><li>2&ndash;4 years of experience in healthcare data analytics, clinical research data analysis, or value-based care programs.</li><li>Hands-on experience working with clinical datasets, research data, or population health data.</li><li>Experience working with <b>Athena EMR/EHR</b> systems for reporting, patient data extraction, workflow analysis, or operational support.</li></ul><p>Technical Skills</p><ul><li><b>Power BI (2+ years)</b> &ndash; dashboarding and visualization</li><li><b>Power Query (2&ndash;3 years)</b> &ndash; data transformation</li><li><b>SQL</b> &ndash; data extraction and manipulation</li><li>Experience navigating and reporting from <b>Athena EMR</b></li><li>Strong skills in data cleaning, validation, and analysis</li></ul><p>Domain Knowledge</p><ul><li>Understanding of CMS programs, MSSP, and HCC risk adjustment</li><li>Familiarity with clinical research processes, datasets, and reporting standards</li><li>Experience with EMR/EHR systems, especially <b>Athenahealth / Athena EMR</b>, and population health tools</li></ul><p>Preferred Qualifications</p><ul><li>Experience supporting clinical trials, registry data, or outcomes-based research</li><li>Knowledge of study design, cohort analysis, and healthcare quality measures (e.g., HEDIS)</li><li>Exposure to statistical tools such as R or Python is a plus</li></ul><p>Job Type: Full-time</p><p>Work Location: In person</p>

Clinical Data Analyst (Athena Experience Required)

North East Medical Services

<div><div><div>The Clinical Data Scientist serves as a strategic bridge between clinical operations, Epic analytics and research initiatives at NEMS. This role will design, build, and validate reproducible analytical workflows and machine learning models using clinical and real‑world data (EHR, claims, registries) to answer clinical and operational questions, support research and product development, and enable data‑driven decision making across the organization.</div></div><p>
</p><div><div><b>ESSENTIAL JOB FUNCTIONS:</b></div></div><p>
</p><ul><li><div>Acts as liaison between IT, clinical informatics, operations and research teams to ensure alignment on clinical data strategy</div></li><li><div>
Designs and executes study and analysis plans for clinical research, outcome measurement, and predictive modeling.</div></li><li><div>
Analyzes patient populations to identify care gaps, utilization patterns, and opportunities for preventive interventions</div></li><li><div>
Supports value-based care initiatives by calculating and monitoring quality measures that impact reimbursement and funding</div></li><li><div>
Collaborates with care management, population health and other operational teams where needed to optimize provider engagement, patient engagement and outreach campaigns</div></li><li><div>
Partners with interdepartmental leaders, clinical directors and quality teams to gather requirements and prioritize analytics projects</div></li><li><div>
Serves as SME for analytics team; validates clinical workflows and data definitions</div></li><li><div>
Extracts, cleans, harmonizes, and curates clinical and real‑world datasets (EHR, claims, labs, device data), ensuring provenance and reproducibility.</div></li><li><div>
Develops feature engineering pipelines and statistical or machine‑learning models (risk scores, phenotyping algorithms, prognostic/predictive models)</div></li><li><div>
Validates models using appropriate methods (cross‑validation, temporal validation, external cohorts) and assesses fairness, calibration, and clinical utility</div></li><li><div>
Collaborates closely with clinicians, biostatisticians, product managers, and engineers to translate clinical questions into analytic specifications and actionable outputs</div></li><li><div>
Implements production‑ready pipelines and supports model deployment, monitoring, and lifecycle management (versioning, performance tracking, drift detection)</div></li><li><div>
Ensures compliance with data governance, privacy, and security requirements (HIPAA best practices); participates in data access and IRB processes as needed</div></li><li><div>
Produces clear, reproducible documentation, analysis code, technical reports, and visualizations for both technical and non‑technical stakeholders</div></li><li><div>
Contributes to team best practices: code review, unit/integration testing for analytics code, and reproducible research practices (notebooks, containers, CI/CD)</div></li><li><div>
Tracks project timelines, deliverables and stakeholder satisfaction metrics using project management tools &ndash; Jira or similar</div></li><li><div>
Performs other job duties as required by manager/supervisor</div></li></ul><ul><li><div>
Clinical Degree: MD, DO, NP, PA, PharmD, or equivalent clinical training with active understanding of clinical workflows, diagnoses, and treatment protocols preferred</div></li><li><div>
MS in Data Science, Biostatistics, Epidemiology, Computer Science, Biomedical Informatics, or related quantitative discipline (or equivalent experience or related field).</div></li><li><div>
5+ years&rsquo; experience working with clinical or real‑world healthcare data (EHR, claims, registries) in applied analytics or research settings</div></li><li><div>
Experience working with underserved or immigrant populations; cultural competency and multilingual skills highly valued</div></li><li><div>
Epic Certification required or must obtain within 6 months of hire</div></li></ul><p>
</p><div><div><b>Technical Skills and Competencies</b>:</div></div><ul><li><div>
Data Visualization tools (Power BI, Tableau or similar)</div></li><li><div>
Strong programming skills in Python and/or R; proficiency with SQL for large‑scale data extraction and manipulation</div></li><li><div>
Deep understanding of quality measures (HEDIS, eCQM), value-based care models and population health principles</div></li><li><div>
Experience with healthcare data standards and APIs (FHIR, HL7) and common EHR systems (Epic, Cerner) preferred</div></li><li><div>
Strong analytical rigor and attention to detail</div></li><li><div>
Excellent written and verbal communication skills with experience presenting technical results to clinicians and stakeholders</div></li><li><div>
Proactive problem solver with a bias for reproducible, production‑quality work</div></li><li><div>
Comfortable with ambiguity and rapidly evolving requirements in healthcare settings</div></li></ul><p>
</p><div><div><b>LANGUAGE:</b></div></div><p>
</p><ul><li><div>Must be able to fluently speak, read and write English</div></li><li><div>
Fluent in Chinese (Cantonese and/or Mandarin), Vietnamese, Spanish and other languages preferred</div></li><li><div>
Fluency in other languages are an asset</div></li></ul><p>
</p><div><div><b>STATUS:</b></div></div><p>
</p><ul><li><div>This is an FLSA Exempt position.</div></li><li><div>
This is not an OSHA low-risk position.</div></li><li><div>
This is a Full Time position.</div></li></ul><p>
NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.</p><p>
NEMS BENEFITS: Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k).<br>
</p><p>#LI-DNI</p></div>

CLINICAL DATA SCIENTIST

NeighborHealth

<div><div><p><b>Thank you for your interest in a career at NeighborHealth, formerly East Boston Neighborhood Health Center!</b></p><p></p><p>
As one of the largest community health centers in the country, NeighborHealth is proud to serve the greater Boston area with a strong commitment to the health and well-being of our patients and communities.</p></div><p></p><div><p>
Whether you're a nurse or physician providing direct care, a manager leading dedicated teams, or part of the essential support staff who keep our operations running smoothly &mdash; every role at NeighborHealth is vital. Together, we&rsquo;re advancing medicine and delivering the best care experience for our patients and community!</p></div><p></p><div><div><div><p>
Interested in this position? Apply online and create a personal candidate account!</p></div></div></div><p></p><p><b>
Current Employees of </b><b>NeighborHealth</b>- Please use our internal careers portal to apply for positions.</p><p></p><p>
To learn more about working at NeighborHealth and our benefits, please visit out our Careers Page.</p><p></p><p><b>
Time Type:
</b></p>Full time<p></p><p><b>
Department:
</b></p>Quality<p></p><p><b>
All Locations:
</b></p>10 Gove Street &ndash; Taylor Building, 151 Orleans Street, 20 Maverick Square &ndash; Cradock Building, 300 Ocean Avenue &ndash; Revere, 79 Paris Street<p></p><p><b>
Position Summary:
</b></p>NeighborHealth is seeking an experienced Quality analyst. This role is ideal for a professional with deep expertise in data management, EMR (Epic) reporting, dashboard build and management, data analysis, and Quality/Process improvement, with an ability to work collaboratively in cross-functional teams and translate data into actionable steps.<p>
The <b>Quality Analyst</b> plays a key role in advancing the health center&rsquo;s strategic projects on quality, population health, and performance improvement. This position is responsible for collecting, validating, analyzing, and reporting clinical and operational data to support organizational priorities. Working closely with senior leadership, the analyst produces dashboards, supports UDS and regulatory reporting, and provides actionable insights that drive improvements in patient outcomes and overall performance.</p><p><i>
The successful candidate will be able to perform the following responsibilities:</i></p><p><b>
Quality Measurement &amp; Reporting</b></p><ul><li><p>
Develop, maintain, and analyze quality performance reports including <b>UDS, HEDIS, PCMH, CMS</b>, and internal quality measures.</p></li><li><p>
Extract, validate, and manage data from <b>Epic</b> using Reporting Workbench and other internal reporting tools.</p></li></ul><p><b>
What You&rsquo;ll Bring</b></p><ul><li>
Bachelor&rsquo;s degree in <b>Public Health, Healthcare Administration, Data Analytics</b>, or related field.</li><li><b>
1&ndash;3 years</b> of experience in healthcare quality, data analysis, or population health.</li><li>
Strong proficiency in <b>Microsoft Excel</b>.</li><li>
Experience with data visualization (charts, graphs, dashboards).</li><li>
Familiarity with quality improvement methodologies.</li><li>
Knowledge of <b>SQL</b>.</li><li>
Experience with <b>Epic Reporting Workbench, Slicer Dicer</b>, or other Epic reporting tools.</li><li>
Understanding of <b>UDS, HEDIS, PCMH</b>, and other clinical quality metrics.</li></ul><p><b>
Preferred</b></p><ul><li><b>
Epic Cogito</b> certification.</li><li>
Experience working in an <b>FQHC</b> or community health center environment.</li><li>
Additional experience with other reporting/analytics tools.</li><li>
Demonstrated background supporting population health and value based care initiatives.</li></ul><ul><li><p>
Produce monthly and quarterly dashboards aligned with organizational quality priorities.</p></li><li><p>
Track performance against quality goals and communicate updates to leadership and operational teams.</p></li></ul><p><b>
Data Analysis &amp; Visualization</b></p><ul><li><p>
Clean, organize, and analyze large datasets using <b>Microsoft Excel</b> and other tools.</p></li><li><p>
Create clear, compelling charts and visualizations to support data-driven decision making.</p></li><li><p>
Identify patterns and trends; collaborate with teams to design actionable and measurable improvements.</p></li></ul><p><b>
Quality Improvement Support</b></p><ul><li><p>
Participate in quality initiatives using <b>PDSA cycles</b>, root cause analysis, workflow mapping, and related methodologies.</p></li><li><p>
Support clinical and operational teams with data validation and monitoring intervention outcomes.</p></li><li><p>
Assist in documentation and reporting for <b>PCMH</b> and accreditation requirements.</p></li></ul><p><b>
Operational &amp; Clinical Support</b></p><ul><li><p>
Support population health activities including <b>panel management</b>, care gap reporting, and related analytics.</p></li><li><p>
Provide routine and ad‑hoc data analysis for clinical and administrative teams.</p></li><li><p>
Conduct ongoing audits and validation to maintain high standards of data integrity.</p></li></ul><p><b>
Other Duties:</b></p><p>
Please note, this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.</p><p><b>
EEO &amp; Accommodation Statement:</b></p><p>
NeighborHealth is an equal employment/affirmative action employer. We ensure equal employment opportunities for all, without regard to race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic. If you need accommodation for any part of the application process because of a medical condition or disability, please send an e-mail to HRrecruit@NeighborHealth.com or call 617-568-4480 to let us know the nature of your request</p><p><b>
Federal Trade Commission Statement:</b><br>
According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website. We do not ask or require downloads of any applications, or &ldquo;apps.&rdquo; Job offers are not extended over text messages or social media platforms. We do not ask individuals to purchase equipment for or prior to employment.</p><p><b>
E-Verify Program Participation Statement:</b></p><p>
NeighborHealth participates in the Electronic Employment Verification Program, E-Verify. As an E-Verify employer, all prospective employees must complete a background check before beginning employment.</p></div>

Analyst, Quality

Blue Shield of California

<div>
 <strong>
  Job Description
  <br/>
  <br/>
 </strong>
 <strong>
  Your Role
  <br/>
  <br/>
 </strong>
 The Clinical Quality team oversees and is responsible of HEDIS medical record review, pursuit, and overall HEDIS submission. The Clinical Quality Coordinator, Entry will report to the Supervisor of the HEDIS Outreach Team. In this role you will be responsible for conducting provider outreach during the HEDIS season for medical record pursuit and retrieval. Also, participation in Quality initiatives involving member outreach for care gap closure. Responsible for maintaining high productivity and standard work.
 <br/>
 <br/>
 Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow &ndash; personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.
 <br/>
 <br/>
 <strong>
  Responsibilities
  <br/>
  <br/>
 </strong>
 <strong>
  Your Work
  <br/>
  <br/>
 </strong>
 <strong>
  In this role, you will:
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Initiate outbound calls to members and providers to collect information and provide care coordination assistance in obtaining services (schedule appointments, provider appointment reminders, coordinate transportation, etc.)
  </li>
  <li>
   Educate members on missing care gaps and provide encouragement to obtain missing service.
  </li>
  <li>
   Request medical records from PCP/Specialists by fax, remote EMR access or scheduled site visits as needed
  </li>
  <li>
   Manage and maintain HEDIS files and medical records
  </li>
  <li>
   Provide administrative support, including generating correspondence, organize mass mailings, coordinator schedules and training
  </li>
  <li>
   Continued development of understanding of HEDIS hybrid measures and medical record requirements for HEDIS compliance
  </li>
  <li>
   Research member claims and encounters to identify accurate pursuit information for medical record retrieval
  </li>
  <li>
   Review medical records and identify elements for compliance
  </li>
  <li>
   Create and maintain detailed logs of member and provider interactions
  </li>
  <li>
   Ability to de-escalate situations
  </li>
  <li>
   Assist in onboarding contingent workforce for HEDIS and outreach projects
  </li>
  <li>
   EMR and vendor portal medical record retrieval
  </li>
  <li>
   Developing understanding of HEDIS pursuit processes relative to pursuit systems and tracking processes
  </li>
  <li>
   Developing understanding of outreach and pursuit project intake procedures, schedules, and reporting requirements
  </li>
  <li>
   Ability to work independently in a fast-paced environment with minimal errors
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Qualifications
  <br/>
  <br/>
 </strong>
 <strong>
  Your Knowledge and Experience
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Requires a high school diploma or equivalent
  </li>
  <li>
   Requires limited knowledge of systems and procedures
  </li>
  <li>
   Typically, has limited or no prior experience
  </li>
  <li>
   Communication and interpersonal skills
  </li>
  <li>
   Must be organized with the ability to keep accurate notes and records
  </li>
  <li>
   Customer service experience is preferred
  </li>
  <li>
   HEDIS knowledge strongly preferred
  </li>
  <li>
   Critical thinking skills
  </li>
  <li>
   Knowledge of computer applications including Microsoft Word, PowerPoint and Excel. Internet knowledge with the ability to complete searches
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Hybrid Virtual Work
  <br/>
  <br/>
 </strong>
 This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.
 <br/>
 <br/>
 <strong>
  About The Team
  <br/>
  <br/>
 </strong>
 <strong>
  About Blue Shield of California
  <br/>
  <br/>
 </strong>
 As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.
 <br/>
 <br/>
 At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
 <br/>
 <br/>
 To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.
 <br/>
 <br/>
 Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities &ndash; join us!
 <br/>
 <br/>
 <strong>
  Our Values:
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
  </li>
  <li>
   Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
  </li>
  <li>
   Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Our Workplace Model
  <br/>
  <br/>
 </strong>
 We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:
 <br/>
 <br/>
 <ul>
  <li>
   For most teams, this means coming into the office two days per week.
  </li>
  <li>
   Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
  </li>
  <li>
   For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.
   <br/>
   <br/>
  </li>
 </ul>
 The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.
 <br/>
 <br/>
 <strong>
  Physical Requirements:
  <br/>
  <br/>
 </strong>
 Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.
 <br/>
 <br/>
 Please click here for further physical requirement detail.
 <br/>
 <br/>
 <strong>
  Equal Employment Opportunity:
  <br/>
  <br/>
 </strong>
 External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.
</div>


Clinical Quality Coordinator, Entry

<div><p><b>Your Role<br>
</b></p><p><br>
The Clinical Quality team oversees and is responsible of HEDIS medical record review, pursuit, and overall HEDIS submission. The Clinical Quality Coordinator, Entry will report to the Supervisor of the HEDIS Outreach Team. In this role you will be responsible for conducting provider outreach during the HEDIS season for medical record pursuit and retrieval. Also, participation in Quality initiatives involving member outreach for care gap closure. Responsible for maintaining high productivity and standard work.<br>
</p><p><br>
Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow &ndash; personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.</p></div>
<br><div><p><b>Your Work
</b></p><p><b>In this role, you will:
</b></p><ul><li>Initiate outbound calls to members and providers to collect information and provide care coordination assistance in obtaining services (schedule appointments, provider appointment reminders, coordinate transportation, etc.)
</li><li>Educate members on missing care gaps and provide encouragement to obtain missing service.
</li><li>Request medical records from PCP/Specialists by fax, remote EMR access or scheduled site visits as needed
</li><li>Manage and maintain HEDIS files and medical records
</li><li>Provide administrative support, including generating correspondence, organize mass mailings, coordinator schedules and training
</li><li>Continued development of understanding of HEDIS hybrid measures and medical record requirements for HEDIS compliance
</li><li>Research member claims and encounters to identify accurate pursuit information for medical record retrieval
</li><li>Review medical records and identify elements for compliance
</li><li>Create and maintain detailed logs of member and provider interactions
</li><li>Ability to de-escalate situations
</li><li>Assist in onboarding contingent workforce for HEDIS and outreach projects
</li><li>EMR and vendor portal medical record retrieval
</li><li>Developing understanding of HEDIS pursuit processes relative to pursuit systems and tracking processes
</li><li>Developing understanding of outreach and pursuit project intake procedures, schedules, and reporting requirements
</li><li>Ability to work independently in a fast-paced environment with minimal errors</li></ul></div>
<br><div><p><b>Your Knowledge and Experience
</b></p><ul><li>Requires a high school diploma or equivalent
</li><li>Requires limited knowledge of systems and procedures
</li><li>Typically, has limited or no prior experience
</li><li>Communication and interpersonal skills
</li><li>Must be organized with the ability to keep accurate notes and records
</li><li>Customer service experience is preferred
</li><li>HEDIS knowledge strongly preferred
</li><li>Critical thinking skills
</li>Knowledge of computer applications including Microsoft Word, PowerPoint and Excel. Internet knowledge with the ability to complete searches<br>
<li>
</li></ul><p></p><p><b>Hybrid Virtual Work
</b><br>
This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.</p></div>
<br><p></p><div><p><b>ABOUT THE TEAM<br>
About Blue Shield of California
</b></p><p>As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.
</p><p>At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
</p><p>To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.
</p><p>Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities &ndash; join us!
</p><p><b>Our Values:
</b></p><p></p><ul><li><b>Honest. </b>We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
</li><li><b>Human. </b>We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
</li><li><b>Courageous. </b>We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
</li></ul><div><p><b>Our Workplace Model
</b></p><p>We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:
</p><ul><li><p>For most teams, this means coming into the office two days per week.
</p></li><li><p>Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
</p></li><li><p>For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.
</p></li></ul><p>The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.
</p></div><p></p><p><b>Physical Requirements:
</b></p><p>Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.</p><p><br>
</p><p><b>Equal Employment Opportunity:
</b></p><p>External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.</p></div>

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