QCI Specialist I

Job Description

Job Description

Description

About the Role

The QCI Specialist I is responsible for supporting quality improvement initiatives that drive performance across HEDIS, Medicare Stars, Medicaid, Commercial, and other quality programs. This role collaborates with provider practices, health plans, and internal stakeholders to improve quality outcomes, close care gaps, support practice transformation efforts, and enhance provider performance. The QCI Specialist I provides practice-level support for quality improvement programs, provider education activities, population health initiatives, quality reporting, and care gap closure strategies while serving as a trusted resource to providers and practice staff.

• Put Patients First
• Empower Entrepreneurial Provider and Care Teams
• Operate with Integrity & Excellence
• Be Innovative
• Work As One Team

Quality Performance & Program Management

• Support day-to-day execution of quality improvement programs, provider performance initiatives, and population health strategies.
• Monitor provider performance against HEDIS, Medicare Stars, Medicaid, Commercial, and other quality measures; analyze results and recommend improvement opportunities.
• Collaborate with providers and practice staff to implement care gap closure, outreach, education, and quality improvement interventions that support achievement of performance targets.
• Collect, validate, and submit medical record documentation and quality data to ensure accurate reporting, measurement, and compliance.

Provider & Practice Engagement

• Partner with provider practices through onsite and virtual engagement to improve quality performance, operational effectiveness, and patient outcomes.
• Provide education and serve as a subject matter resource on HEDIS, Medicare Stars, NCQA standards, documentation requirements, quality reporting, and performance improvement strategies.
• Present performance results, best practices, and recommendations while maintaining strong relationships with providers, health plans, and internal stakeholders.

Practice Transformation & Performance Improvement

• Support practice transformation initiatives through workflow analysis, process redesign, EHR optimization, documentation improvement, and population health management activities.
• Develop and implement improvement plans, identify performance barriers, and collaborate with providers and care teams to drive sustainable quality and operational outcomes.
• Support projects and initiatives designed to enhance service delivery, clinical quality, patient experience, and overall practice performance.

Compliance & Operational Excellence

• Support quality audits, medical record reviews, and regulatory compliance activities in accordance with NCQA, CMS, HIPAA, and health plan requirements.
• Maintain accurate documentation of quality initiatives and provider engagement activities while identifying opportunities to improve operational effectiveness.
• Participate in provider, training, and organizational meetings and perform other duties or special projects as assigned.

Education

• Bachelor's degree in Healthcare Administration, Public Health, Business Administration, Nursing, or a related field preferred, or equivalent combination of education and relevant experience.

Experience

• At least 1 year of experience in healthcare, managed care, population health, quality improvement, provider engagement, or related healthcare programs preferred
• At least 1 year of experience supporting HEDIS, quality improvement, Medicare Stars, or quality reporting initiatives preferred
• Experience working with provider practices, IPAs, MSOs, health plans, or outpatient clinical settings preferred.
• Experience analyzing provider performance data and supporting quality improvement interventions preferred.
• Familiarity with practice management operations, workflow improvement, and population health strategies preferred.

License/ Certifications (if applicable)

• No certification is required.
• Certified Professional in Healthcare Quality (CPHQ) or other relevant healthcare quality certification preferred.

Knowledge, Skills, and Abilities

• Strong knowledge of managed care operations, quality improvement programs, HEDIS, Medicare Stars, NCQA standards, HIPAA requirements, population health management, and quality reporting methodologies.
• Working knowledge of quality measure specifications, practice transformation, workflow redesign, EHR optimization, and documentation improvement strategies.
• Strong analytical, critical-thinking, problem-solving, and organizational skills, with the ability to identify opportunities, implement solutions, and manage multiple priorities effectively.
• Excellent provider relationship management, stakeholder engagement, communication, presentation, and interpersonal skills, with the ability to work independently and collaboratively across provider groups and internal departments.
• Intermediate proficiency in Microsoft Excel, PowerPoint, reporting tools, and data analytics applications.
• Demonstrated professionalism, accountability, integrity, attention to detail, and commitment to high-quality outcomes.
• Fluency in Spanish and/or Portuguese preferred.

Preferred Qualifications

• Experience supporting HEDIS, Medicare Stars, quality improvement, population health, provider performance, and practice transformation initiatives.
• Experience working within Medicare Advantage, Medicaid, Commercial, or other managed care environments.
• Experience conducting provider education, staff training, workflow redesign, and quality performance improvement activities.
• Experience collecting, validating, analyzing, and reporting medical record and quality performance data to support operational and quality outcomes.

• This position may collaborate with providers, practice staff, health plans, and internal stakeholders in remote, office, and provider office settings.
• The employee must reside in Rhode Island, Massachusetts, or Connecticut.
• Travel up to 50% may be required to support provider practices and organizational initiatives.
• The employee must be able to attend meetings in person or virtually based on business needs.
• Work requires regular use of computers, electronic health record systems, reporting platforms, and virtual communication tools.
• The employee must comply with Astrana Health policies and procedures regarding patient privacy, protected health information, and all applicable federal and state regulations.