Fallon Health

  • RN -Quality Oversight & Improvement Coordinator - Looking for a new Career? Fallon Health Insurance!

    Location US-MA-Worcester
    Posted Date 3 weeks ago(3 weeks ago)
    Job ID
    5354
    # Positions
    1
    Category
    Nursing
  • Overview

    About Fallon Health

    Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.

     

    Job Summary
    This position is accountable for supporting the delivery system to improve member’s health outcomes, oversight of assigned delegated activities  and participation in the company’s STARS and GIC quality improvement initiatives by: 1) Assisting providers to deliver improved patient care. 2) Educating the provider community on impact of CAHPS, HOS and HEDIS on member outcomes and STARs performance. 3) Assessing provider office practices for opportunities that positively impact member experience and impact HEDIS, CAHPS and HOS ratings.  This position will be required to communicate and collaborate with value based and non-valued based partners as well as other stakeholders to effectively manage the delivery of strategies, plans and improvements to HEDIS, Medicare Stars, GIC Quality Improvement Initiatives, Qualified Health Plans/Quality Rating Systems and other clinical quality measurements. Knowledge and utilization of health analytic tools is required to identify opportunities to improve satisfaction and quality.

    Responsibilities

    Primary Job Responsibilities

    • Provides staff education on the health plan’s STAR & GIC initiatives, to include HEDIS, CAHPS and HOS surveys as it relates to improving member experience and health outcomes.
    • Utilize health analytic tools to identify trends and opportunities (within a population in a specific geographic area)
    • To enhance the health of Fallon Health members and support value based arrangements and collaborative care providers with management of their members.
    • Assist members to obtain preventive screenings and review for adherence with prescribed medications
    • Obtain supplemental data contained in the medical record and make it available to the health plan for integration into the HEDIS data base.
    • Inform and educate the care team on care gaps, activities, issues or concerns about the population and from the value based programs.

    • Collaborate with Member, Member’s Personal Representative, Member’s Physicians, Plan Medical Directors, Managers, as well as other functional area to assist the member to meet their health care goals, reduce care gaps, improve health outcomes, and reduce the total cost of care.
    • Identify and report on healthcare disparities within a geographic region.
    • Oversight of assigned delegated medical management functions
    • Responsibility for monitoring and tracking of delegate’s performance to ensure they are meeting or exceeding contracted service level agreements.
           
    • Analyzes and summarizes delegate reports and audits and identifies variances and trends
    • Maintains the First Tier Auditing and Monitoring (FTEAM) Universe on an ongoing basis
    • Be familiar with abstracting clinical data from EMRs
    • HEDIS data collection using NCQA Certified HEDIS Software to prospectively collect data during the measurement year.
    • Assist in medical chart review and data collection during HEDIS season.

    Perform other duties as assigned.

    Qualifications

     

    Qualifications Requirements

    • Current Massachusetts RN licensure
    • Bachelors’ degree in related field (i.e. Nursing, Healthcare, Business) or equivalent experience
    • 4+ years’ experience in health insurance or managed care (defined as previous experience with health plan/hospital compliance, risk management).
    • Previous case management experience preferred.
    • Experience or working knowledge of HEDIS, Stars and the Qualified Health Plan/Quality Rating System
    • Ability to interact with medical staff, peers, and internal company staff at all levels
    • Non-traditional working hours to meet the member’s availability
    • Basic to intermediate experience in MS Word, Excel, tablet and/or smartphone
    • Travel up to 30% (subject to change) for on-site member/provider meetings, events or manager requests.
    • Must have valid driver's license and reliable transportation
    • Ability to talk and type simultaneously
    • Flexibility 


    Must be able to work in a multi-functional team setting

    Preferred Criteria

    • Intermediate experience and or knowledge of HEDIS/Stars/CMS/Quality preferred
    • Intermediate health care data management and project management skills
    • Experience with healthcare quality improvement strategies

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