Clinical Quality Manager

Description and Requirements The Clinical Quality Manager works with members and providers to ensure members receive appropriate services. This role emphasizes improving the quality of care with a focus on HEDIS, QARR and Medicare Advantage Star measures.

Duties & Responsibilities: Interacts with hospitals, providers, and members to improve quality of care, monitor progress, and recommend changes Reviews billing codes, medical records, and claims submission processes to ensure accuracy Attends and facilitates any initiative meetings (studies, partnerships) that involve targeted providers and/or measures Completes on-site provider visits to implement work plans and conduct provider education sessions regarding appropriate coding practices and chart documentation Collaborates with other departments to maximize member outreach for preventive services and chronic disease management Assists in writing member and/or provider articles on HEDIS, QARR, Medicare Advantage, and/or health promotions for the HF newsletter Assists and supports regulatory affairs Document all relevant interactions in appropriate systems Additional duties as necessary Minimum Qualifications: Associate's degree from an accredited institution Ability to travel around the NYC metro area Preferred Qualifications: Bachelor's Degree from an accredited institution Clinical license: LPN, RN, LMSW or LCSW Multiple years of HEDIS review experience for both Medicaid and Medicare lines of business Medical record review experience directly working on HEDIS/QARR in a managed care setting Good presentation, relationship management, and analytical skills Intermediate MS Word, Excel, and PowerPoint Compliance & Regulatory Responsibilities: Noted above License/Certification: N/A Hiring Range : Greater New York City Area (NY, NJ, CT residents): $83,100 - $120,360 All Other Locations (within approved locations): $73,400 - $108,160 As a candidate for this position, your salary and related elements of compensation will