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*Clinical HEDIS Practice Advisor, RN (Registered Nurse) Atlanta, GA-1401578

IBM Type Full time Posted 4/23/2014
Salary - n/a - Starts - n/a -
GA - Georgia (All) - Atlanta Referral - n/a -    
About WellCare: WellCare Health Plans, Inc. provides managed care services targeted to government-sponsored health care programs, focusing on Medicaid and Medicare. Headquartered in Tampa, Fla., WellCare offers a variety of health plans for families, children, and the aged, blind and disabled, as well as prescription drug plans. The company serves approximately 3.3 million members nationwide as of January 1, 2014. The company employs more than 5,100 nationwide. For more information about WellCare, please visit the company's website at www.wellcare.com. A Fortune 500 company traded on the New York Stock Exchange (symbol: WCG).

EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, sex, age forty (40) and over, disability, veteran status, or national origin.

Provides education and consultation to providers’ and provider practice sites in regards to the National Committee for Quality Assurance (NCQA) HEDIS measures. Serves as the market clinical subject matter, expert in the field, for HEDIS measures, appropriate medical record documentation and appropriate coding. Supports the development and implementation of quality improvement interventions and audits in relation to plan providers. Assists in resolving deficiencies impacting plan compliance to meeting State and Federal standards for HEDIS. Interfaces with a diverse range of clinical and administrative professionals, resolves complex issues, and performs data analytic and reporting activities.

Essential Functions:

  • Functions as HEDIS subject matter expert in consultation with provider practices.
  • Advises and educates Provider practices in appropriate HEDIS measures, medical record documentation guidelines and HEDIS ICD-9 / CPT coding in accordance with NCQA requirements.
  • Collects, summarizes and trends provider performance data to identify and strategize opportunities for provider improvement.
  • Collaborates with Provider Relations to improve provider performance in areas of Quality, Risk Adjustment, Operations (claims and encounters).
  • Conducts internal auditing for provider compliance with regulatory and NCQA accreditation standards, and monitors and provides consultation to departments to correct deficiencies.
  • Communicates with external data sources as needed to gather data necessary to measure identified outcomes.
  • Provides communication such as newsletter articles, member education, outreach interventions and provider education.
  • Ensures accuracy in medical records for data collection, data entry and reporting. Enters documentation of findings in identified databases.
  • Conducts additional ad hoc QI audits through medical record review. Provides education for providers around individual state regulatory requirements, health laws, and reporting requirements.
  • Supports quality improvement program studies and HEDIS as needed, requesting records from providers, maintaining databases, and researching to identify members' provider encounter history.
  • Maintains HIPAA standards and confidentiality of protected health information. Reports critical incidents and information regarding quality of care issues.
  • Ensures that documentation produced and/or processed complies with state regulations and/or accrediting body requirements.
  • Ensures assigned contract/regulatory report content is accurate and that submission adheres to deadline.
  • Works independently, under the supervision of the Quality Management leader.
  • Participates in or coordinates with other department projects as needed.
  • Participates in and represents plan at community, health department, collaborative and other organizational meetings focusing on quality improvement, member education, and disparity programs, as assigned.
  • Performs other duties as assigned.
Additional Responsibilities:
 Candidate Education:
  • Required          Other Clinical license as an RN, pharmacist, LCSW, MD, DO, APRN, ANP, CPHARM, etc.
  • Required          A Bachelor's Degree in nursing, pharmacy or medical equivalent discipline equivalent to or higher than a RN if associate/candidate is not licensed or does not hold a current license in state job is located
Candidate Experience:
  • Required           2+ years of experience in directly related HEDIS medical record review and/or Quality Improvement with experience in clinical data/chart reviews and providing clinical consultation and education to providers and provider staff
  • Required           1+ year of experience in Managed care health services environment
Candidate Skills:
  • Advanced       Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
  • Advanced       Demonstrated interpersonal/verbal communication skills
  • Intermediate       Ability to multi-task
  • Advanced       Ability to work in a fast paced environment with changing priorities
  • Intermediate       Ability to implement process improvements
  • Advanced       Ability to effectively present information and respond to questions from families, members, and providers
  • Advanced       Ability to influence internal and external constituents
  • Intermediate       Demonstrated analytical skills
  • Advanced       Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
  • Advanced       Other Understanding of data analysis and continuous quality improvement process
Licenses and Certifications:
  • Required          Position should hold a "clinical" license in one of the following shown below. LPN, LSW, LMHC etc DO NOT QUALIFY for this position but rather the HEDIS Practice Advisor. If the candidate/associate does not hold a current license, they must possess a medical equivalent Bachelor's degree/education plus ample experience in HEDIS review and/or quality improvement
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  • Required          International Medical Degree
Technical Skills:
  • Required          Intermediate       Microsoft Excel
  • Required          Intermediate       Microsoft Access
  • Required          Intermediate       Microsoft PowerPoint
  • Required          Intermediate       Microsoft Outlook

Primary Location



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