To learn more about Arkansas Blue Cross and Blue Shield Hiring Policies, please click here.Applicants must be eligible to begin work on the date of hire. Applicants must be currently authorized to work in the United States on a full-time basis. ARKANSAS BLUE CROSS BLUE SHIELD will NOT sponsor applicants for work visas in this position.Arkansas Blue Cross is only seeking applicants for remote positions from the following states:Arkansas, Florida, Georgia, Illinois, Kansas, Louisiana, Minnesota, Mississippi, Oklahoma, South Carolina, Tennessee, Texas, Virginia and Wisconsin.RemoteJob SummaryThis position primarily provides orientations, tools, and resources that educate on preferred behaviors and encourage performance on Stars measures while incentivizing physician behaviors that are in alignment with these measures. The person in this role is expected to work directly with healthcare providers to build relationships, ensure effective education and reporting, and to proactively identify performance improvement opportunities through analysis and discussion with subject matter experts. The role will also collaborate on various member related programs.RequirementsEDUCATION
Bachelor's degree in Nursing, Business, or other health-related field preferred. In lieu of degree, five (5) years' experience in quality improvement, managed care, Medicare functional areas required.
LICENSING/CERTIFICATION
Valid Driver's license with the ability to travel, as necessary, within the designated
service area required.
Healthcare license (RN, LPN, PharmD, LMSW etc.) desirable but not required
EXPERIENCE
Minimum four (4) years' in a health plan, managed care setting or direct provider quality leadership.
Minimum three (3) years' quality performance improvement including HEDIS/Stars.
Minimum two (2) years' direct HEDIS involvement including hybrid medical record collection/review and abstraction.
Experience with healthcare claims data required.
Medicare experience required.
Experience with quality improvement programs/campaigns related to HEDIS or Stars measures.
Has a solid working knowledge with NCQA (HEDIS) technical specifications.
Demonstrated experience managing/ influencing stakeholders through collaborative partnerships preferred.
Experience preparing for and facilitating quality meetings through review of analytics, development of strategic plans, and partnering with key entities preferred.
Strong knowledge of Medicare population and interworking's preferred.
Demonstrated history of successful project management desired.
Bilingual a plus.
*Must reside in the state of Arkansas*
ESSENTIAL SKILLS & ABILITIES
Strong written and oral communication skills interacting with individuals internally and externally.
Strong independent, critical thinking skills to understand individual and operational problems and identifying appropriate solution(s).
Ability to function independently and travel across the state of Arkansas to meet with various providers/provider groups to discuss ABCBS programs focused on improving the quality of care for Medicare Advantage members.
Knowledge of and ability to work within a complex health care system including advocating for member needs while balancing provider needs.
Ability to work well on their own as well as with a team and know how to conduct and interpret quantitative and qualitative analyses.
SkillsResponsibilitiesActively participate in Stars Committees and Stars Workgroups, Collaborate across departments, including but not limited to provider network, risk, quality, CMDM, to implement interventions to improve performance for health outcomes, Cooperate and assist with the implementation of the HEDIS and PQA strategy for Stars measures, Develop and grow positive, long-term relationships with physicians, providers, and health care systems to support in the development of quality improvement plans and growth, Develop materials and presentations for utilization during meetings based upon collaboration with internal data teams, external vendor partners, and other stakeholders, Develop performance improvement intervention/campaigns to improve the HEDIS/Stars measures or other identified quality improvement measures, Identify issues related to Stars performance, research root cause, and then work to remediate issues, Participate in the annual HEDIS chart retrieval process including EMR medical record retrieval, abstraction, overreads, claims research for appropriate provider of care, provider outreach and issue resolution, Partner with member outreach specialists for more complex case reviews and interventions, as appropriate and escalated by the member outreach team, Partner with the Stars Managers to develop and implement HEDIS/Stars outreaches and share input and direction for continuous improvement, Perform regular meetings with health care entities to review performance, opportunities for gap closure, and develop quality improvement programs through sharing of best practice information, Proactively identify performance improvement opportunities through analysis and discussion with subject matter experts; and influence provider behavior to achieve needed results., Responsible for assisting in program implementation and provider performance management, which is tracked by designated provider metrics, including Stars gap closure and risk coding accuracy, Responsible for non-standard supplemental abstraction and overreads, Serve as an educational resource and partner on Star measures through creation of materials and assisting with design of letters or communications included in improvement initiatives and campaignsCertificationsSecurity RequirementsThis position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.
Segregation of DutiesSegregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.
Employment TypeRegularADA Requirements
1.1 General Office Worker, Sedentary, Campus Travel - Someone who normally works in an office setting or remotely and routinely travels for work within walking distance of location of primary work assignment.
