Provider Quality Specialist
FIDELIS CARE OFFERS QUALITY, AFFORDABLE COVERAGE TO RESIDENTS ACROSS THE STATE OF NEW YORK, INCLUDING PRODUCTS AVAILABLE THROUGH MEDICAID, MEDICARE AND THE NY STATE OF HEALTH. FIDELIS CARE WAS FOUNDED ON THE BELIEF THAT ALL NEW YORKERS SHOULD HAVE ACCESS TO AFFORDABLE, QUALITY HEALTH INSURANCE AND THAT REMAINS OUR MISSION TO THIS DAY TO OUR MORE THAN 1.4 MILLION MEMBERS.
Supports departmental and corporate goals, in conjunction with the AVP, Provider Relations, and Provider Quality Specialists, by working directly with providers to optimize the results of quality initiatives; educates key providers on all aspects of various quality initiatives, including QARR and HEDIS; works collaboratively with Provider Relations, QHCM, and IT to provide timely and accurate information related to quality initiatives to internal and external customers.
* Educate key providers in assigned regions on all aspects of quality programs including QARR and HEDIS measures.
* Educate providers on the proper use of report cards and related member outreach.
* Educate providers on the processes related to medical record submission and corrected claims.
* Facilitate retrieval of Fidelis Care New York's member healthcare records to ensure achievement of optimum QARR and HEDIS scores; assist in the retrieval of both Medicaid and Medicare member health care records.
* Collaborate with Provider Relations and QHCM so that outreach is coordinated and records are tracked in a consistent manner.
* Maintain subject matter expertise in QARR and HEDIS measures as well as the Quality Care Management Incentive Program.
* Proficiency in Microsoft Office: Excel, Word, Access; Lotus Notes; Internet.
* Knowledge of various quality programs, including measures associated with QARR and HEDIS.
* Ability to lead or coordinate projects within own department.
* Business Analysis Knowledge: Skilled to work in a fast paced environment.
* Must have strong analytical and problem solving skills.
* Customer Service: Skilled to communicate with all levels of management, internal and external customers.
* Ability to work well as a member of a team or alone.
* Effective Business Communication: Skilled in communicating with technical and business constituencies in writing effective business specifications and requirements.
WORK RELATED EXPERIENCE:
* Five to eight years experience working in a managed care environment.
* Five to eight years related experience required.
EDUCATION, LICENSE, AND CERTIFICATION REQUIREMENTS
* BA/BS - Bachelors Degree or equivalent required.