Clinical Quality Manager
HealthFirst
Summary
The Clinical Quality Manager works 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.
Job description
Duties & Responsibilities
- Interacts with hospitals, providers, and members to improve quality of care, monitor progress, and recommend changes
- Reviews billing codes, medical records, and claims submission processes to ensure accuracy
- Attends and facilitates any initiative meetings (studies, partnerships) that involve targeted providers and/or measures
- Completes on-site provider visits to implement work plans and 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 on HEDIS, QARR, Medicare Advantage, and/or health promotions for the HF newsletter
- Assists and supports regulatory affairs
- Document all relevant interactions in appropriate systems
- Additional duties as necessary
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
Requirements
- Associate's degree from an accredited institution
- Ability to travel around the NYC metro area
Benefits
- Medical, Dental & Vision
- Incentive & Recognition Programs
- Life Insurance
- 401(k) Contributions
Company overview
HealthFirst is a medical equipment manufacturing company specializing in the development and production of healthcare devices and diagnostic equipment. As a medical device manufacturer, the company focuses on creating innovative solutions that enhance patient care and improve clinical outcomes. HealthFirst operates in the competitive medical technology sector, where it likely develops products ranging from diagnostic instruments to therapeutic devices used in various healthcare settings. The company's commitment to quality and regulatory compliance positions it as a reliable provider of medical equipment to hospitals, clinics, and healthcare facilities. With expertise in medical device engineering and manufacturing, HealthFirst contributes to advancing healthcare technology while maintaining rigorous standards for safety and efficacy. The company's products are designed to meet the evolving needs of healthcare professionals and patients, supporting improved diagnosis, treatment, and monitoring of medical conditions across different therapeutic areas.