Performance Programs Specialist

Job Description

Under the direction of Performance Programs leadership team, the Performance Program Specialist will assist in the coordination of IHA/AMP self reporting audit, roadmap and health plan audit preparation, data collection, reporting processes and any quality improvement activities to improve clinical performance measures for all lines of business (Commercial, Medicare, Medical). Additionally, this position will take a lead role in coordinating the efforts to improve performance measures and is responsible for coordination activities related to the HEDIS and IHA/AMP measures. Serves as the liaison with Network Management, Medical Management, IT and other ad hoc departments and programs as necessary.

Responsibilities

• Coordinate completion of IHA and HEDIS roadmaps. Provide timely measure status reporting, including trending and analyzing of the data.
• Reconcile health plan care in gap (CIG) reports with internal PMS data to interpret, communicate, and present results in a consistent and easy-to-understand format that facilitates fact-based decision making.
• Development and execution of intervention steps to improve targeted measures. Define objectives, processing requirements, and specifications to document steps taken and results achieved related to HEDIS/P4P results.
• Create ad-hoc reports to assist with the tracking of HEDIS/P4P measures. Display initiative in researching beyond the specific assignment. Develop and respond to HEDIS/P4P Audit Corrective Action Plan (CAP) as necessary.
• Develop and maintain the HEDIS/P4P training manual and documentation in accordance with department standards, including industry best practices. Work with the Manager to set medical records review (MRR) standards for HEDIS/P4P for quality assurance purposes.
• Assist with writing P&Ps to document standards for review. Responsible for HEDIS/P4P reporting software and quality assurance goals. Ensure compliance with standards of the HEDIS/P4P compliance audits.
• Assist the Manager in the coordination and preparation of the HEDIS/P4P medical record review, which includes ongoing review of records submitted by providers and the annual HEDIS/P4P medical record review.
• Identify member service gaps based on data loaded in the HEDIS engine (Cozeva) and come up with plan to close those gaps in care. Collect medical records and reports from provider offices based on member-needed services reports and gaps, and load data into the HEDIS engine (Cozeva).
• Assist the Quality Care Coordinators with physician and member interventions and incentive efforts as needed. Provide data collection and report development support for Quality Improvement activities and performance improvement projects.
• Assist as needed in support of accreditation activities such as NCQA reviews, CAHPS, and state audits. Assists Manager and Supervisor(s) in training and takes the lead role in these activities, utilizing the standardized training materials and job aids.
• Visit provider offices as needed for in person training on HEDIS measures and how to abstract/close care gaps in HEDIS engine (Cozeva). Assist abstractors in overreading attestations in HEDIS engine (Cozeva) to close care gaps. Work with provider offices to schedule members, as needed.
  
  

Qualifications

Minimum Education: Bachelor’s degree or equivalent experience required.

Minimum Experience: A minimum of three (3) to four (4) years of IPA/HMO experience in P4P/HEDIS Programs. Advanced knowledge of HEDIS and NCQA.

Req. Certification/Licensure: None.

About Us

With approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island. Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services. Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare. For 25+ years, Prospect Medical has been focused on our mission of supporting independent physicians where, through risk arrangements, we work closely together with health plans, facilities and healthcare physicians for the benefit of every person who comes to us for care. We provide quality healthcare services that are designed to offer our patients highly coordinated, personalized care and that help them live healthier lives. Prospect Medical Systems manages highly successful IPAs by leveraging our best-practices, results-driven administrative services to manage patients under risk arrangements with health plans/CMS.