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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in HEDIS improvement activities, quality assurance, and medical management systems while effectively communicating and training stakeholders on regulatory requirements and data analysis.
Highest-signal resume keywords
HEDIS Improvement ActivitiesRegistered Nurse (RN) LicenseQuality AssuranceData AnalysisMedical Management Systems
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Quality AssuranceUtilization ManagementCase ManagementHealth Care InformaticsData AnalysisMedical TerminologyHEDIS Technical SpecificationsRegulatory ComplianceMedical-Record AbstractionLEAN Principles
Soft Skills
Interpersonal SkillsCommunication SkillsProblem-Solving CapabilityAttention to DetailProject Management
Tools & Technologies
Microsoft Office SuiteMicrosoft AccessMedical Management Systems
Certifications & Qualifications
Registered Nurse (RN) License
Industry Keywords
HEDISNCQAManaged CareHealth Plan ProcessesRegulatory Requirements
About the role
Key responsibilities & impact- Provide support to the Supervisor, Clinical Quality Improvement, and IEHP departments on HEDIS improvement-related issues
- Serve as a resource for internal and external customers
- Interpret clinical data for quality-improvement studies for medical management
- Maintain working knowledge of medical management systems, business processes, and workflows
- Maintain summarized information for Quality Systems regarding modified and new regulatory requirements from DHCS, DMHC, and CMS
- Act as liaison between the QI/HEDIS department and other departments, practitioners, and providers
- Train departments on HEDIS-related measures
- Participate in development, research, and implementation of HEDIS improvement activities
- Support and educate the QI/HEDIS Coordinator in CRM activities, HEDIS data entry, and related activities
- Manage outreach and education projects related to HEDIS, Supplemental Data, and quality-improvement initiatives
- Develop training materials, conduct presentations and information sessions, and provide targeted outreach
- Review and perform quality-assurance checks of supplemental data files
- Participate in medical-record abstraction and accuracy validations for HEDIS hybrid pursuit
- Track regulatory changes and inform Quality Systems management of significant modifications
- Maintain knowledge of data sources used for regulatory compliance
- Troubleshoot medical-management report requests and determine user needs and objectives
- Analyze, interpret, and translate complex clinical data, issues, trends, and relationships into strategies and action plans
- Incorporate LEAN principles into daily work
- Perform other duties required for Health Plan operations and department business needs
Requirements
What you’ll need- Three (3) or more years of any individual or combined experience in quality assurance, utilization management, case management, and/or health care informatics
- Associate's degree in Nursing from an accredited institution required
- Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required
- Experience in an HMO or managed care setting preferred
- Advanced knowledge of NCQA HEDIS technical specifications, medical terminology, and health plan processes preferred
- Advanced knowledge of current medical management systems and how information is stored and retrieved
- In-depth understanding of current HEDIS technical specifications, with ability to interpret changes and clarifications accurately
- Basic knowledge of Microsoft Access
- Data analysis and computer applications, including word processing, databases, and spreadsheets
- Proficient in Microsoft Office Suite
- Excellent interpersonal/communication skills
- Ability to handle multiple projects and data input
- Strong problem-solving capability
- Strong attention to detail
Benefits
Comp & perks- Competitive salary
- State of the art fitness center on-site
- Medical Insurance with Dental and Vision
- Life, short-term, and long-term disability options
- Career advancement opportunities and professional development
- Wellness programs that promote a healthy work-life balance
- Flexible Spending Account – Health Care/Childcare
- CalPERS retirement
- 457(b) option with a contribution match
- Paid life insurance for employees
- Pet care insurance
- Approved telecommute work location
- Periodic mandatory in-person meetings or other business-related campus reporting may be required