Clinical Specialist - Integrated Health/HEDIS

Under the general supervision of the Director of Integrated Care, the Clinical Specialist – Integrated Health/HEDIS/Quality contributes to quality improvement functions and is an active contributor to DWIHN’s implementation/enhancement of new and existing healthcare quality improvement initiatives and education programs.

 PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Contributes to quality improvement functions and is an active contributor to DWIHN’s implementation/enhancement of new and existing healthcare quality improvement initiatives and education programs.
• Ensures maintenance of programs for members in accordance with prescribed quality standards.
• Conducts member outreach activities.
• Provides necessary education and guidance to close identified gaps in care.
• Maintains and ensures necessary reporting and monitoring for key intervention activities.
• Works to improve HEDIS scores while improving the overall health of members by providing education on clinically recommended care.
• Provides coordination and support to assist members in obtaining needed services.
• Develops, writes and maintains effective Quality Improvement plans based on NCQA requirements.
• Implements and monitors Quality Improvement Plans within DWIHN and the Provider Network.
• Places outreach calls to members identified as having gaps in care.
• Educates members on the importance of care and needed screenings.
• Follows up with members requiring support in taking steps to close care gaps.
• Evaluates Health Related Social Needs that may impact the member’s ability to access needed services.
• Evaluates ongoing care management needs and makes referrals as necessary.
• Participates in Quality Workgroups focused on HEDIS, and other quality measures.
• Records member interactions in the clinical documentation system.
• Creates Quality improvement projects and design interventions.
• Provides follow-up on the results of interventions and documents findings and limitations.
• Demonstrates and maintains current working knowledge of required systems, procedures, forms, and manuals
• Complies with all NCQA accreditation requirements as well as other state and federal regulations.
• Facilitates quality improvement intervention activities meetings and discussions within DWIHN.
• Creates and maintains policies & standard operating procedures of processes to maintain compliance.
• Supports programs and clinical best practices with the objective of improving health outcomes, preventing hospital readmissions, discharge follow-ups, medication adherence, improving member safety and reducing medical errors, and promoting health and wellness activities.
• Serves as lead analyst to provide project, program, and / or initiative-related direction and guidance for DWIHN.
• Develops, runs, and/or prepares formatted reports to support critical Quality Improvement functions (e.g., reporting for key performance measurement activities, including HEDIS, state-based measure reporting and medical record review).
• Collaborates and / or assists in performing quality assurance checks on reports prior to completion.
• Works with the Director to establish document quality assurance process checks to be utilized by all staff to ensure the integrity, completeness and validity of external and internal reports.
• Collaborates with department leads and other partnering departments to understand and document business requirements and implement required reporting.
• Writes and produces accurate reports and conducts analyses according to set timelines and project plans.
• Collaborates with other department staff to convert HEDIS data sources for use in HEDIS reporting.
• Maintains up-to-date knowledge and understanding of specifications for all HEDIS measures.
• Coordinates data and analyses from the HEDIS platform and internal DWIHN reports.
• Assists with generation of State-specific performance measurement requirements.
• Develops and maintains an effective, professional working relationship with providers and their staff.
• Develops performance measures that support business objectives.
• Supports providers in closing treatment opportunities (HEDIS/Star measures).
• Recommends, communicates, and implements solutions to identify problems and the root cause of issues.
• Generates a summary of monthly activity and details how progress will be implemented or achieved.
• Performs related duties as assigned.

KNOWLEDGE, SKILLS AND ABILITIES (KSA’S):

• Knowledge of DWIHN policies, procedures, and practices.
• Knowledge of the DWIHN provider network and community resources.
• Knowledge of the Michigan Mental Health Code.
• Knowledge of MDHHS policies, rules, regulations, and procedures.
• Knowledge of Federal policies, rules, regulations, and procedures as it relates to DWIHN.
• Knowledge of behavioral health and mental health principles and practices.
• Knowledge of the Michigan Medicaid Provider Manual.
• Knowledge of MHWIN.
• Knowledge of the clinical care process (screening, assessment, treatment planning, case management and continuing care).
• Knowledge of Integrated Care services for behavioral health patients.
• Knowledge of compliance standards.
• Knowledge of Medical Necessity Criteria for Behavioral Health Services.
• Knowledge of NCQA requirements and the accreditation process.
• Knowledge of HEDIS measures and standards.
• Knowledge of the Federal Confidentiality Regulations, 42 CFR, Part 2.
• Knowledge of Community Mental Health Services Programs (CMHSP) and Prepaid Inpatient Health Plans (PIHP).
• Knowledge of care coordination rules and protocols.
• Knowledge of Quality Management and Quality Improvement principles and practices.
• Assessment skills.
• Evaluation skills.
• Organizational skills.
• Report writing skills.
• Decision Making skills.
• Communication skills.
• Coordination skills.
• Computer skills (Word, Excel, Access, Power Point, Outlook, Teams).
• Teamwork Skills.
• Ability to communicate orally.
• Ability to communicate in writing.
• Ability to work effectively with others.
• Ability to work with an ethnically, linguistically, culturally, economically, and socially diverse population.
• Judgement/Reasoning ability.

 REQUIRED EDUCATION:

A Master’s Degree in a Clinical field of study, Public Health, Healthcare Administration, Health Management, or closely related field.

REQUIRED EXPERIENCE:

Three (3) years of full-time paid professional experience working in a human service, social service, mental health, or behavioral health setting performing duties and responsibilities in the following areas:

• HEDIS Audits
• NCQA or related certification
• Quality Management/Quality Improvement

 REQUIRED LICENSE(S).

A Valid State of Michigan clinical licensure:   RN, LMSW, LMHC, LPC, LLP or PhD. 

 A valid State of Michigan Driver’s License with a safe and acceptable driving record.

 WORKING CONDITIONS:

Work is usually performed in an office setting but requires the employee to drive to different sites throughout Wayne County and the State of Michigan.  This position can work remotely with supervisory approval.   Currently this position is primarily a remote position.

This description is not intended to be a complete statement of job content, rather to act as a general description of the essential functions performed.  Management retains the discretion to add or change the position at any time. 

Please Note:  DWIHN requires proof of being fully vaccinated for COVID-19 as a condition of employment. Medical or religious accommodations or other exemptions that may be required by law, will be approved when properly supported. Further information will be provided during the recruitment process. 

The Detroit Wayne Integrated Health Network is an Equal Opportunity Employer