HEDIS Audit Specialist
HEDIS Audit Specialist
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Job Description
People. Passion. Purpose.
At P3 Health Partners our promise is to guide our communities to better health unburden clinicians align incentives and engage patients.
We are a physicianled organization relentless in our mission to overcome all obstacles by positively disrupting the business of health care transforming it from sickness care into wellness guidance.
We are looking for a HEDIS Audit Specialist. If you are passionate about your work; eager to have fun; and motivated to be part of a fastgrowing organization in Stockton California then you should consider joining our team.
Overall Purpose:
The HEDIS Audit Specialist supports the P3 Care Enablement Teams and national quality initiatives under the guidance of the National Quality Manager. This role involves conducting specific audits to ensure that nonstandard supplemental data submissions are sufficient for closing care gaps in accordance with HEDIS Technical Specifications. The position also includes performing data mining for selected groups and identifying trends in submissions as well as opportunities for education. Furthermore the HEDIS Audit Specialist will assist with audit requests from various health plans.
The National Quality Team ensures adherence to policies and procedures as mandated by but not limited to the Centers for Medicare and Medicaid Services (CMS) the National Committee on Quality Assurance (NCQA) and the respective health plans.
Education and Experience:
- An associate degree in a related field or equivalent experience is required.
- A minimum of 4 years of experience in healthcare with a focus on managed care is essential.
- At least 2 years of prior experience in a quality role within a health plan setting specifically conducting peer reviews is necessary.
- Intermediate to advanced proficiency in Microsoft Office programs particularly Excel.
- Must be detailoriented with a strong focus on solutions.
Knowledge Skills and Abilities:
- Knowledge of CMS HEDIS Specifications and health plan regulatory requirements as well as managed care and health plan standards
- Strong analytical and critical thinking abilities.
- Experience in data mining.
- Proficient in navigating multiple systems.
- Capable of working independently as well as collaboratively within a team.
- Excellent verbal and written communication skills with the ability to effectively engage with a diverse range of individuals.
Essential Functions:
- Understands the principles of CMS HEDIS NCQA Health Plan Quality Standards CAHPS HOS and HIPAA
- Supports the National Quality Department by auditing nonstandard supplemental data submissions to approve or reject them based on CMSs HEDIS Specifications thereby enhancing performance.
- Identifies educational needs by analyzing trends in nonstandard supplemental data submissions.
- Participates in data collection through medical record and claims surveillance.
- Assists the National Quality Manager in onboarding training and auditing new Provider Operations Coordinators.
- Works to optimize health plan and healthcare provider performance on quality measures through effective auditing practices.
- Engages in National Quality meetings and other related initiatives.
- Understands the operation of P3 machines (such as diabetic eye cameras and bone density machines).
- Responds to inquiries from health plans providers and interdepartmental teams with a focus on exceptional customer service.
- Reviews provider group gap uploads via the P3 Health Hub.
- Collaborates with the National Quality Team to create and maintain Standard Operating Procedures (SOPs) for nonstandard supplemental data submissions.
- Takes a proactive role in positioning P3 Medical Group as a leading medical group in quality (acknowledging that this may vary in other markets).
- Performs other duties as assigned.
SMART GOALS:
- Monthly:
- 100% nonstandard supplemental data submission review
- 250 gap attempts per month
- Quarterly
- Identify trends related to nonstandard supplemental data submission at the market level
- Provides feedback to leadership and markets regarding audit findings
- Annual:
- Assist with health plans annual audit requests
- Partner with National Quality to create and maintain departmental SOPs
Required Experience:
Unclear Seniority
Employment Type
Full-Time
