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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in managing HEDIS and prenatal-postpartum populations, conducting medical record reviews, and ensuring compliance with regulatory standards. Proficient in quality improvement interventions and effective communication with healthcare providers and members.
Highest-signal resume keywords
Licensed Practical Nurse CertificationHEDIS ManagementMedical Record ReviewQuality Improvement InterventionsRegulatory Agency Standards Familiarity
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Quality Data CollectionCare CoordinationPreventive Health Guidelines EducationData DocumentationPopulation Outcomes Improvement
Soft Skills
Critical ThinkingOrganizingCollaborationCommunication
Tools & Technologies
Quality DatabaseHealth Plan Quality Plans
Certifications & Qualifications
Licensed Practical Nurse Certification
Industry Keywords
HEDISNCQAPrenatal-Postpartum ServicesHealth ChoicesQuality Standards
About the role
Key responsibilities & impact- Manage annual and proactive HEDIS (PAH) activities for compliant and non-compliant populations
- Manage Health Choices/Commercial prenatal-postpartum (PNPP) populations as assigned
- Conduct outreach to assigned HEDIS/PNPP member caseloads
- Perform retrospective medical record reviews to collect clinical quality data under NCQA HEDIS/PNPP specifications
- Collaborate with health plan members and primary care providers across multiple practice sites
- Facilitate clinical guideline adherence and coordinate services
- Contribute to quality improvement interventions and Health Plan Quality and Work Plans
- Participate in regulatory agency standards education
- Execute interventions to improve population outcomes and quality rates/rankings
- Review physician progress notes, laboratory data, radiology/imaging reports, and consult notes
- Document medical record data accurately in the Quality database
- Review targeted measures and coordinate follow-up care
- Track member compliance reports and intervene with non-compliant members
- Educate physicians, provider office staff, members, and site personnel on quality standards and preventive health guidelines
- Support prenatal/postpartum services, risk assessment, care coordination, health and nutrition education, and preventive screenings
- Participate as a voting member in the member appeals process when needed
- Identify process improvement opportunities and assist management with implementation
- Report quality or potential fraudulent issues
- Refer members to Health and Case Management when appropriate
Requirements
What you’ll need- At least three (3) years of LPN work experience
- Minimum of 5 years of nursing experience
- Graduate from Specialty Training Program-Nursing (Required)
- Licensed Practical Nurse certification/license
- Familiarity with medical record review
- Familiarity with regulatory agency standards
- Computer literacy
- Critical thinking
- Organizing
- Ability to work Monday–Friday, 8:00am–4:30pm
- Travel to assigned provider offices and community outreach events may be required
Benefits
Comp & perks- Full benefits (health, dental and vision) starting on day one
- Three medical plan choices, including an expanded network for out-of-area employees and dependents
- Pre-tax healthcare and dependent care flexible spending accounts (FSA)
- Health savings account (HSA)
- Company-paid life insurance
- Short-term disability coverage
- Long-term disability coverage
- 401(k) plan with automatic Geisinger contributions
- Generous paid time off (PTO) plan
- Up to $5,000 in tuition reimbursement per calendar year
- MyHealth Rewards wellness program with a financial incentive
- Adoption and fertility assistance
- Parental leave pay
- Military leave pay
- Free Care.com membership with discounted backup care
- Employee Assistance Program (EAP)
- Free legal guidance
- Mental health visits
- Work-life support
- Digital self-help tools
- Voluntary accident insurance
- Critical illness insurance
- Hospital indemnity insurance
- Identity theft protection
- Universal life insurance
- Pet insurance
- Legal insurance
- Healthcare benefits for full-time and part-time positions from day one, including vision, dental and domestic partners