Clinical Quality Specialist

Job Description

Job Description

  Job Title: Clinical Quality Specialist
Reports to: Director, Medical Management

The Clinical Quality Specialist supports the Clinical Quality Nurse in overseeing the HEDIS quality collection, submission, reporting, and auditing as well as assists with education to support the MyTruAdvantage line of business.

Key Responsibilities:

• Knowledge of current HEDIS guidance, hybrid measure reporting, and measure compliance requirements.
• Collaborate with Clinical Quality Nurse and internal data analyst to oversee HEDIS quality gap distribution to health partners and member providers for HEDIS clinical data collection.
• Participate in communication with health partners regarding process of clinical document submission, annual education on applicable HEDIS measures, and cadence of reporting.
• Help identify opportunities for improved or expanded HEDIS data collection.
• Participate in internal chart chasing efforts.
• Assure proper internal secure storage of HEDIS data collected from external providers.
• Participate in Medical Record Review clinical submissions processes, assuring accuracy and completeness.
• Support outreach efforts to external providers to collect clinicals needed for reporting.
• Assist with maintaining all HEDIS related guidelines, policy & procedures, and auditing documents necessary for successful annual HEDIS audits.
• Active participant in any external HEDIS audits performed as needed.
• Support internal Chronic Care Improvement Program initiatives as needed.
• Participate in internal or external process improvement efforts that support the quality improvement and collection efforts necessary for the Medicare Advantage or commercial lines of business. (Accurate provider attributions, training of health partners, training of new internal staff etc.)

Minimum Skills Requirement:

• CMA or experience in clinical documentation review preferred.
• Experience in working for or with HEDIS data collection and reporting preferred.
• Proficiency in Microsoft Office Suite (Outlook, Word, Excel, PowerPoint).
• Experience with electronic medical records and using online tools.
• Ability to communicate professionally with physicians and office staff to facilitate organizational initiatives.
• Willingness to obtain applicable HEDIS certifications deemed appropriate for position.

We may use artificial intelligence (AI) tools to support parts of the hiring process, such as reviewing applications, analyzing resumes, or assessing responses and identifying potential inconsistencies or verification signals in application materials based on available information. These tools assist our recruitment team but do not replace human judgment. Final hiring decisions are ultimately made by humans. If you would like more information about how your data is processed, please contact us.