Quality & Risk Adjustment Specialist
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Job Location:
Sioux Falls, SD - USA
Monthly Salary:
$ 20 - 27
Posted on:
30 days ago
Vacancies:
1 Vacancy
Job Summary
Location:
Worker Type:
RegularWork Shift:
Day Shift (United States of America)Pay Range:
The pay range for this position is listed below. Actual pay rate dependent upon experience.
$20.50 - $27.00Position Highlights
Monday- Frida 8:00am-5:00pm; 80 hours 2 weeks
No weekends
You Belong at Avera
Be part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. Work where you matter.
A Brief Overview
Responsible for activities focused around Risk Adjustment (RA) initiatives and Healthcare Effectiveness Data Information Sets (HEDIS). The Quality and Risk Adjustment Specialist will work closely with the Director of Quality and Risk Services Manager of Risk Adjustment Manager of Quality Quality Coordinator HEDIS coder(s) claims staff and primary care & specialty care providers to ensure that proper clinical documentation. The QRA Specialist will be responsible for ensuring that medical records for identified members are retrieved reviewed and documented appropriately for all Quality and RA initiatives.
What you will do
- Understand the rationale behind Risk Adjustment Work with physicians clinic staff coding and other Health Plans staff to resolve coding or work process issues in regards to RA.
- Supports clinic RA visits & audits.
- Responsible for ensuring appropriate parties complete designated RA tasks General understanding of Hierarchical Condition Coding Oversight of External Data Gathering Environment (EDGE) submission process.
- Observes investigates and reports any trending issues which may cause quality or RA gaps.
- Expand job related knowledge through participation in approved continuing education and in-services including offsite meetings and webinars in regards to Risk Adjustment and HEDIS.
- Supports annual RADV (Risk Adjustment Data Validation) audit with multiple Health Plans departments.
- Participates in HEDIS abstraction efforts in collaboration with Quality Coordinator HEDIS.
- Supports member and provider outreach initiatives to close quality and RA gaps.
- Identifies opportunities for synergies related to medical record review and manages the medical record request process for Quality and RA.
Essential Qualifications
The individual must be able to work the hours specified. To perform this job successfully an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others hear understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge skills and abilities required to perform the essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions as long as the accommodations do not cause undue hardship to the employer.
Required Education License/Certification or Work Experience:
- 4-6 years professional experience in insurance or managed care industry.
Preferred Education License/Certification or Work Experience:
- Bachelors or combination of education and experience
Expectations and Standards
- Commitment to the daily application of Averas mission vision core values and social principles to serve patients their families and our community.
- Promote Averas values of compassion hospitality and stewardship.
- Uphold Averas standards of Communication Attitude Responsiveness and Engagement (CARE) with enthusiasm and sincerity.
- Maintain confidentiality.
- Work effectively in a team environment coordinating work flow with other team members and ensuring a productive and efficient environment.
- Comply with safety principles laws regulations and standards associated with but not limited to CMS The Joint Commission DHHS and OSHA if applicable.
Benefits You Need & Then Some
Avera is proud to offer a wide range of benefits to qualifying part-time and full-time employees. We support you with opportunities to help live balanced healthy lives. Benefits are designed to meet needs of today and into the future.
PTO available day 1 for eligible hires.
Up to 5% employer matching contribution for retirement
Career development guided by hands-on training and mentorship
Avera is an Equal Opportunity Employer - Qualified applicants will receive consideration for employment without regard to race color religion sex national origin disability Veteran Status or other categories protected by law. If you are an individual with a disability and would like to request an accommodation for help with your online application please call 1- or send an email to .
Required Experience:
IC
Key Skills
- Interventional Radiology
- Information Technology Sales
- Jdbc
- Glass
- Architecture
