October 06, 2016
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Clinical Qual Imprv. Liaison

Horizon Blue Cross Blue Shield of New Jersey - Trenton, NJ

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Job Description

Job Summary:

This position is responsible for managing HEDIS and Stars performance by working with low performing providers to identify areas of opportunity. The CQA will be the main Quality contact for providers, they will provide guidance and resources in order for the provider to achieve target Quality Performance metrics, as established by the National Committee for Quality Assurance.


* CQA is the main liaison for the Quality Management department and all assigned provider groups to improve HEDIS and Stars Quality Performance.

* Monitor and analyze provider Quality Performance Reports. Identify areas of improvement, provide assistance with root cause analysis, assists with developing solutions, and develop a work plan to monitor progress.

* Conduct 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.

* Collaborate with Value Based Programs and Provider Contracting and Services to manage provider quality performance.

* During HEDIS season, assists with the retrieval of charts, chart abstraction, and chart review entries. CQM must adhere to the HEDIS guidelines for chart review abstractions and standards.

* Provide HEDIS provider guidelines that highlight appropriate HEDIS codes for claims submission.

* Assists in the development of member and provider outreach, engagement, and education materials to improve Quality Performance.

* Completes other assigned functions, including special projects, as requested by management.


* Requires 4 Year Degree or 4 years of relevant years of work experience.

* Requires a minimum of three (3) years experience in a healthcare setting: health plan, hospital, physician practice, or managed care organization.

* Prefers experience in continuous quality improvement and/or quality management.

Additional licensing, certifications, registrations:

* LPN, RN, LMSW or LCSW required.


* Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Microsoft Outlook. Should be knowledgeable in the use of intranet and internet applications.

* Prefers knowledge of Population Health Management and Preventative Management Programs.

* Prefers Project Management skills.

Skills and Abilities:

* Requires excellent verbal and written communication skills.

* Analytical & Problem Solving.

* Continuous Improvement.

* Information & Knowledge Sharing.

* Process Management.

* Interpersonal & Client Relationship.

* Presentation Skills.

Travel % (If Applicable):

* 30% Travel to Provider Offices.

The information above is intended to describe the general nature of the work being performed by each incumbent assigned to this position. This job description is not designed to be an exhaustive list of all responsibilities, duties, and skills required of each incumbent.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.



Job Level
Individual Contributor

--Horizon NJ Health

Job Type
Full Time

Trenton, NJ