Lead HEDIS Specialist

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.

At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements:

• Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week

• Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week

• Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month

• Onsite: daily onsite requirement based on the essential functions of the job

• Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building

Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week.

This position is hybrid within the state of AZ only. This hybrid work opportunity requires residency, and work to be performed, within the State of Arizona.

PURPOSE OF THE JOB

This position is responsible for National Committee for Quality Assurance Healthcare Effectiveness Data and Information Set’s (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS®) initiatives, including leading all aspects of training, implementation and reporting of medical record retrieval, review (MRR) and overread.

REQUIRED QUALIFICATIONS

Required Work Experience

• 2 years/seasons of HEDIS medical record review experience, with at least one season of over-read responsibilities.
• 2 years of training or overseeing staff
• 3 years’ experience in a clinical, health plan or health information management environment

Required Education

• High-School Diploma or GED in general field of study

Required Licenses

• None

Required Certifications

• None

PREFERRED QUALIFICATIONS

Preferred Work Experience

• 5 years’ experience in a clinical and/or health plan environment

Preferred Education

• Bachelor's degree in business, public health, nursing, or related area

Preferred Licenses

• Active or inactive license in any state or territory of the United States as a Licensed Vocational Nurse, Licensed Practical Nurse, Registered Nurse, or similar license

Preferred Certifications

• Certified coder or similar credential in health information management
• Certified in healthcare quality or project management

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

• Supports the design, piloting, and monitoring of various HEDIS/Stars projects; oversees implementation as assigned.
• Develops policies, procedures, and training materials; delivers training.
• Initiates and project manage the validation of supplemental data sources (“primary source verification”).
• Ensures self and team maintain subject matter expertise on all means to close HEDIS gaps and exclusions, new medical technologies, medications and how to find this data in the legal health record.
• Monitors and addresses accuracy and productivity issues.
• Leads MRR and related HEDIS compliance audit deliverables,
• Oversees and performs project management of assignments from beginning to end establishing timelines, coordinating, monitoring, troubleshooting, summarizing, and reporting on project deliverables. Observes, tracks and reports opportunities for improvement and effective practices.
• Onboards new abstraction/retrieval staff
• Internal customers include corporate administrators, management team and staff.
• External customers include accreditation and regulatory organizations, peer review organizations, payers, patients, healthcare providers, clinical registries, and databases.
• The position has an onsite expectation of 1 day per week and requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
• Performs all other duties as assigned.

REQUIRED COMPETENCIES

Required Job Skills

• Manages projects--independently sets timelines, coordinates, monitors, troubleshoots, summarizes, and reports on project deliverables
• Independently troubleshoots basic desktop/login issues, using the Help Desk if needed
• Advanced proficiency with a variety of software applications and/or vendor tools that are used to manage and/or conduct HEDIS activities
• Software proficiencies—basic Microsoft Teams and email and Outlook calendar skills; basic Excel skills, including filter and sort; highlight, mark up and remove pages from pdfs; file management in OneDrive/Windows Explorer, electronic medical records (EMR), electronic disease registries and/or health information exchanges (HIE)
• Familiarity with the legal health record, its contents, search techniques, EMR, HIE, and clinical registries (i.e., immunization registry); ability to interpret and communicate regarding this clinical information in English
• Thrives in a paperless environment
• Manages time and productivity—independently planning, escalations and troubleshooting to ensure deadlines are met
• Anticipates and shifts to new tasks frequently as priorities emerge
• Works on projects whose timelines overlap
• Excellent personal organizational skills, including note taking, to eliminate unnecessary rework
• Creates and utilizes checklists and other quality checks to ensure work is accurate, complete and of high quality
• Proficiency with a variety of software applications and/or vendor tools used to manage and/or conduct HEDIS project
• Working knowledge of NCQA’s HEDIS Compliance Audit deliverables and process
• Analytical knowledge and skills to evaluate and make decisions based on available information
• undefined

Required Professional Competencies

• Independently manages assignments, time, and priorities
• Collaborates and communicates transparently with leadership and coworkers, openness to feedback
• Interprets and applies policies, procedures, performance measure specifications and different measurement methodologies
• Interprets and implements HEDIS or similar technical specifications at an intermediate level; ability to update knowledge when specifications change
• Confirms to all established policies, procedures, and regulations in maintaining confidentiality and privacy
• Exercises independent and sound judgment with good problem-solving skills
• Manages multiple tasks simultaneously in a demanding, fast-paced environment while keeping relevant others in the organization informed of progress
• Successfully works with minimal supervision, seeks out and seizes opportunities, finds ways to surmount barriers, and takes lead roles in working with key stakeholders and other analysts
• Shares important and relevant information with the team. Proactively offers suggestions, provides resources, volunteers for assignments, and removes barriers to help the team accomplish its goals
• Accountability for long- and short-term multi-faceted projects

Required Leadership Experience and Competencies

• Superior ability to effectively engage various audiences under a variety of fast-paced and high-profile circumstances, orally and in writing
• Experience communicating with a high level of discretion and professionalism with physician leaders/office staff, executives, and other stakeholders
• Ability to independently manage technical/complex, multi-staged projects from beginning to end

PREFERRED COMPETENCIES

Preferred Job Skills

• N/A

Preferred Professional Competencies

• Outreach and other improvement initiative skills

Preferred Leadership Experience and Competencies

• Successful experience as a team leader or supervisor

#LI-AB1

Our Commitment

AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.

Thank you for your interest in Blue Cross Blue Shield of Arizona.  For more information on our company, see azblue.com.  If interested in this position, please apply.