General Summary: The HEDIS Specialist will review clinical data from health plans and research within EMR charts and pharmacies. The role performs ongoing analysis of charts for the appropriate compliance review and research and resolves assigned medication adherence projects in collaboration with contracted health plans to assist GMG in reaching for 5-star performance level on quality measures defined by NCQA and adopted by GMG each year. Monitors HEDIS reports for accuracy, searches for missed reporting and improves HEDIS scores.
Supervisory Responsibilities: This position has no supervisory responsibilities.
General Requirements: All duties performed will be done accurately and in a timely manner.
1. Conduct inbound and outbound calls to patients to discuss and assist with medication adherence.
2. Bilingual (English/Spanish) fluency preferred.
3. Research chart thoroughly on medication that is non adherent and contact pharmacies and health plans for medication adherence.
4. Participates in and contributes to the overall pharmacy quality improvement initiatives.
5. Reviews monthly/weekly internal and external HEDIS reports and updates in the EMR to ensure membership counts are as accurate as possible.
6. Updates EMR Patient registration information as needed to keep membership information correct.
7. Meets and maintains production and quality expectations for all assigned measures.
8. Strong attention to detail and exceptional organizational skills are required.
9. Ability to communicate effectively, written and verbally, and rely on extensive experience and judgement to plan and accomplish goals strategically desired.
10. Identifies opportunities for clinical staff to improve workflows to incorporate HEDIS into their day efficiently.
11. Complete abstraction and review of medical records to health plans.
12. Regularly attends Small Group meetings to give HEDIS updates and performance feedback.
13. Works closely with the Director of Clinical Research and Data Analytics in reviewing and validating report accuracy.
14. Collaborates with Contracted Health plans to sponsor Patient Health Fairs that will support the HEDIS.
15. Maintains strictest member and company confidentiality.
16. Other duties as assigned.
Work Environment: Depending upon the area assigned may be 100% clinical setting or office setting in a clinic environment. Exposure to communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations, and other conditions common to a clinic environment.
Mental / Physical Requirements: Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, walking, lifting up to 40 lbs. Close vision and ability to adjust focus. Must be able to work efficiently under pressure.
Additional Information: Gonzaba Medical Group is seeking team members who contribute as A-Players, demonstrate a strong work ethic, are committed to the culture and our core values.
Other Duties As Assigned: The above job description is not intended to be an all-inclusive list of duties and standards of the position. Team members will follow any other instructions, and perform any other related duties, as assigned by their supervisor. Responsibilities, knowledge, skills, abilities, and work environments may change as needs evolve.
