About this role
This role is integral in supporting our mission to advance quality care across our network, particularly within the Southern California IPAs. Reporting to the Manager of Quality Care Improvement, the Specialist will serve as a key liaison to lead and coordinate initiatives that drive performance in HEDIS, CMS Star Ratings (Part C & D), and overall health plan quality metrics. Our Values: Put Patients First Empower Entrepreneurial Provider and Care Teams Operate with Integrity & Excellence Be Innovative Work As One Team Build and maintain strong relationships with provider offices and clinic leadership. Conduct onsite and virtual provider outreach visits to review quality performance metrics, identify improvement opportunities, and retrieve relevant care gap closure data/records. Collaborate with assigned provider offices and health plans to improve documentation, coding accuracy, and care gap closure. Collect, review, and validate medical records to ensure accuracy and completeness for reporting purposes. Educate providers and office staff on quality measures, documentation standards, coding requirements, and best practices. Support monthly supplemental data submission, file preparation, and verification of compliant coding. Work with internal teams and vendors to validate, reconcile, and audit HEDIS records to ensure completeness and accuracy. Assist in developing QI initiatives such as outreach campaigns, provider education, and workflow optimization. Assist practices with workflow optimization, patient outreach strategies, and quality improvement interventions. Serve as a quality performance resource to assigned health plan partners, provider groups, clinics, and MSOs, providing and presenting HEDIS performance scorecards monthly. Monitor HEDIS progress dashboards and address data gaps prior to final submission. Prepare reports, scorecards, and presentations for leadership review. Obtain data needed for Primary Source Verification audits from health plans and vendors and ensure timely submission. Act as a subject matter expert on CMS, HEDIS, NCQA, HIPAA, and health plan standards. Conduct comprehensive training for PCPs and specialists on: 1. Quality Measures 2. HEDIS and CMS Star Ratings 3. Performance-Based Incentive Programs 4. Data Accuracy and Documentation Standards Perform additional duties and projects assigned.