Quality Care Coordinator

Job Description

The Quality Care Coordinator (QCC) assists the providers and leadership team in accomplishing the highest percentage of member compliance for the annual goals of HEDIS, IHA, and STAR measures, as well as Annual Wellness Visits. Using Cozeva and other quality platforms, the QCC will enter data from medical record review, document conversations held with members or healthcare providers, and review data on reports. The QCC reviews patient due reports from Cozeva (or similar platforms) and organizes the data in preparation for member outreach. Through a combination of mailing patient due letters or education flyers, calling the patient and/or healthcare provider, creating referrals, and conducting warm-handoffs; the QCC is the professional representative of striving for patient satisfaction. The QCC is also responsible for providing general education related to the quality measures showing “due”, as member outbound or inbound calls are conducted

Responsibilities

• Manage assigned member outreach (appointment calls, quality measures due, annual wellness visits, follow-up calls, etc.) by closing gaps in care and increase HEDIS/IHA/STAR/P4P scores.
• Receive inbound calls from members and assist with tracking data, etc.
• Document details the healthcare provider conducts in quality platforms (Cozeva, etc) communication module for accurate tracking.
• Provide general education to encourage the staff and providers to complete the required, “due” quality measures.
• Input alerts in EMR to notify providers/staff of current outstanding items due for completion.
• Develop and maintain the P4P and HEDIS training manual and documentation in accordance with department standards and industry best practices
• Assist the Manager in the coordination and preparation of the HEDIS medical record review, which includes outgoing review of records submitted by providers and the annual HEDIS medical record review.
• Provide the providers, staff, and members with the nearest contracted Lab location to have lab services rendered.
• Assist as needed in support of accreditation activities such as NCQA reviews, CAHPS, and state audits.
• Ability to create CMS1500 forms from the provider code data
• Ability to discuss with providers the strengths and weakness while coding
• Request medical records from healthcare providers to verify services were rendered, per member’s verbal reporting.
• Follow all departmental Policies and Procedures for audit compliancy.
• Assists outside departments with facilitating PCP transfers, answering questions, and conducting follow-up calls; as needed.
• Populate database with new member demographic information.
• Helps with special projects, as needed.
  
  

Qualifications

Minimum Education: High School Diploma or General Education Development (GED) required.

Minimum Experience: A minimum of three plus (3+) years of IPA/HMO experience and one plus (1+) year/s in P4P/HCC/CMS Star Programs experience. Ability to project excellent customer service, negotiation, and conflict resolution skills via telephone while maintaining a professional demeanor.

Req. Certification/Licensure: None.

"Location-Based Pay Adjustment"

About Us

With approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island. Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services. Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare. For 25+ years, Prospect Medical has been focused on our mission of supporting independent physicians where, through risk arrangements, we work closely together with health plans, facilities and healthcare physicians for the benefit of every person who comes to us for care. We provide quality healthcare services that are designed to offer our patients highly coordinated, personalized care and that help them live healthier lives. Prospect Medical Systems manages highly successful IPAs by leveraging our best-practices, results-driven administrative services to manage patients under risk arrangements with health plans/CMS.