About this role
Serves as a liaison between members, families, and providers to close care gaps and remove barriers to care. Educates providers and members on HEDIS measures and supports scheduling and wraparound services to improve preventive care access and HEDIS outcomes.
Key Responsibilities
- Liaison between member/family, physician, and facilities/agencies
- Educate provider practices on HEDIS measures and HEDIS ICD-10/CPT coding per NCQA
- Identify care gaps and schedule preventive appointments
- Conduct telephonic outreach and health coaching
- Arrange transportation and coordinate wraparound services
Technical Overview
Operationally supports quality improvement by educating on HEDIS measures and HEDIS ICD-10/CPT coding aligned with NCQA requirements. Tracks provider performance data to drive improvements and assists with audits and compliance to State and Federal HEDIS standards.
Ideal Candidate
The ideal candidate lives in California and is experienced in telephonic member outreach and face-to-face education in provider offices. They are comfortable coaching providers and members on HEDIS measures and understand HEDIS ICD-10 and CPT coding aligned to NCQA requirements. They also have strong confidentiality practices and can coordinate care-gap services such as scheduling preventive visits and arranging transportation and wraparound supports.
Must-Have Skills
Must live in CaliforniaTelephonic member outreachPreference for Bi-Lingual Spanish (implied preferred but preference stated)Advise and educate Provider practices in appropriate HEDIS measuresHEDIS ICD-10 /CPT coding in accordance with NCQA requirementsConduct face-to-face education with member and their family in the provider's officeConduct telephonic outreach and health coachingSchedule doctor appointments for members with care gapsArrange transportation and follow-up servicesMaintain confidentiality of business and protected health information
Nice-to-Have Skills
Bi-lingual Spanish
Required Skills
Telephonic outreachface-to-face educationHEDIS measures educationHEDIS ICD-10 codingCPT codingNCQA requirementsquality improvement interventionsauditsprovider performance datarisk adjustmentclaims and encounterstransportation arrangementwraparound servicesprotected health information confidentialityhealth coaching
Hard Skills
Telephonic outreachFace-to-face education with members and familyHEDIS measures educationHEDIS ICD-10 codingHEDIS CPT codingNCQA requirements knowledgeProvider performance data assessmentProvider improvement strategyQuality improvement interventionsAudits in relation to plan providersResolving deficiencies impacting plan compliance to meeting State and Federal standards for HEDISCare gap identification and closureMember scheduling support for preventive servicesTransportation arrangement for membersWraparound services coordinationConfidentiality of business and protected health informationMember outreach and health coaching
Soft Skills
Liaison and advocacyMember/family and provider communicationEducation and coachingEmpathy and patient-centered communicationCollaboration with Provider RelationsRelationship building with provider practicesConfidentiality handlingProblem-solving for barriers to careTime managementCultural/linguistic sensitivity (Spanish bilingual preference)
Keywords for Your Resume
Patient Care Advocatemember outreachtelephonic outreachface-to-face educationcare gapspreventive servicesHEDISHEDIS measuresHEDIS ICD-10ICD-10CPTNCQA requirementsquality improvement interventionsauditsState and Federal standards for HEDISprovider performance dataprovider improvementRisk AdjustmentOperations (claims and encounters)transportation arrangementwraparound serviceshealth coachingprotected health informationconfidentialityWellCaretransportation
Deal Breakers
Must live in California, Telephonic member outreach requirement, Ability to educate providers on HEDIS measures and HEDIS ICD-10 / CPT coding per NCQA requirements
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