Government Programs Clinical Quality & HEDIS Specialist
Full-TimePosted on 9/29/2026
No salary listed
Mid
Bachelor's
Remote in USA
RemoteTravel within the designated service area is required.
About the job
Requirements
A bachelor's degree in Health Science, Public Health, Psychology, Social Work, Health Administration, or another healthcare-related field is required; five years of related experience may substitute, or an associate degree in one of the named fields plus two additional years of related experience may satisfy the education requirement.
A valid driver's license is required.
Must pass the Inter-Rater Reliability (IRR) test within 90 days of hire or assignment, achieving a score of 95%; failure after training and a second attempt may result in disciplinary action.
At least three years of work experience in direct patient care, social work, quality improvement, health coaching, clinical or healthcare service quality improvement, or health data analytics is required; managed care, Stars/HEDIS, or medical record review audit experience is preferred.
At least one year of Medicare Advantage experience is required.
Experience working directly with patients is required.
Ability to work within a complex healthcare system and advocate for member needs while balancing organizational needs.
Ability to understand the needs of culturally diverse populations and evaluate literacy needs.
Written and verbal communication skills for interacting with internal and external contacts.
Independent critical-thinking skills to understand individual and operational problems and identify appropriate solutions.
Interpersonal, presentation, problem-solving, and organizational skills.
Proficiency in Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook, and ability to work independently in these applications with little or no training.
Ability to travel within the designated service area as necessary.
Ability to protect confidential healthcare information and comply with applicable laws, policies, rules, and regulations.
Ability to demonstrate empathy and compassion verbally and by telephone.
Ability to assess needs and design, develop, and implement goal-oriented care plans.
Ability to work in a fast-paced environment with changing priorities.
Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions.
Active licensure or certification as a Registered Nurse (RN), Licensed Practical Nurse (LPN), Licensed Baccalaureate Social Worker (LBSW), or Certified Pharmacy Technician (CPhT) is preferred.
Certified Professional Coder (CPC) certification is preferred but not required.
Bilingual ability is a plus.
Responsibilities
Assist in creating member and practitioner educational materials related to quality management activities and program information.
Assist in implementing new or ongoing quality improvement initiatives.
Build relationships and serve as a liaison and advocate among members, network providers, city or county health departments, and community service organizations.
Review, retrieve, abstract, and overread clinical medical record documentation for HEDIS audit activities and quality-gap provider initiatives, ensuring accuracy and compliance with CMS guidelines.
Develop work and progress plans for members based on interactions and insights.
Help members schedule needed care appointments and navigate the healthcare delivery system.
Identify and triage members to appropriate healthcare resources, care coordination, assistance with medical-care questions, and resolution of barriers to effective use of healthcare resources.
Measure, analyze, and report HEDIS quality initiative results; collaborate to create tools that capture and report relevant information and identify member and provider quality-gap trends.
Perform telephonic outreach and health coaching to members and families regarding medication adherence, preventive-care reminders or reinforcement, and other Stars measures to improve member experience and remove barriers to care.
Assess and evaluate members' service needs and guide them toward optimal wellness and care using motivational interviewing and advocacy.
Support provider outreach initiatives, including sending gap reports and retrieving medical records.
Work with other Stars Member Outreach Specialists, Stars Improvement Nurses, and health plan staff to monitor gap closures and improvement activities.
Complete other activities and projects as directed by the Clinical Quality and HEDIS Leadership team.
Desired Qualifications
Experience as a health navigator, patient navigator, patient advocate, care advocate, or health coach.
Experience working closely with or advocating for culturally diverse individuals or people of lower socioeconomic status.
Strong understanding of HEDIS measures and technical specifications.
Skills and experience in medical record abstraction, claims coding, education, and training.
To learn more about Arkansas Blue Cross and Blue Shield Hiring Policies, please click here.
Job Summary
This position will have split responsibility between HEDIS abstraction and quality work and member/provider engagement to improve overall quality performance. The individual will be responsible for conducting telephonic care coordination for members by identifying opportunities for intervention, including preventative care screenings, disease state management, appropriate medication use, and other key health care needs. This position will access appropriate health-related services and work closely with members, pharmacies, and physicians to help ensure that members have comprehensive and coordinated care to improve clinical government program quality and performance. The specialist will also be responsible for extensive knowledge of HEDIS measures to facilitate abstraction of medical records to allow for gap closure and additional data gathering.
Requirements
EDUCATION
Bachelor’s degree in Health Science, Public Health, Psychology, Social Work, Health Administration, or other healthcare related field. In lieu of degree, five (5) years' related experience will be considered. Likewise, an associate degree in one of the above fields can be used in conjunction with an additional two (2) years' related experience to meet the Education requirement.
LICENSING/CERTIFICATION
Valid Driver’s License
Must successfully pass the Inter-Rater Reliability (IRR) test within 90 days of hire and/or assignment into the position.
An active licensure or certification in one of the following is preferred: Registered Nurse (RN), Licensed Practical Nurse (LPN), Licensed Baccalaureate Social Worker (LBSW), Certified Pharmacy Technician (CPht).
Certified Professional Coder (CPC) preferred, but not required.
EXPERIENCE
Minimum three (3) years' work experience in one of the following:
Direct patient care, social work, quality improvement or health coaching, preferably in a managed care environment OR Clinical, healthcare service quality improvement, or health data analytics, preferably involving Stars/HEDIS® and/or medical record review audit.
Minimum one (1) year of experience in Medicare Advantage required.
Experience working directly with patients required.
Knowledge of and ability to work within a complex health care system including advocating for member needs while balancing organization needs.
Understand needs of culturally diverse populations including ability to evaluate for literacy and literacy needs.
Experience as a health navigator, patient navigator, patient advocate, care advocate, or health coach strongly preferred.
Experience working closely with and/or advocating for individuals who are culturally diverse and/or in positions of lower socioeconomic status preferred.
ESSENTIAL SKILLS & ABILITIES
Must achieve passing score of 95% to align with auditor requirements for passing of IRR test. If, following training and re-test, the employee fails to pass after a second attempt, the employee will be subject to disciplinary action per the terms of the Performance Standards Manual requirements.
Excellent written and verbal communication skills interacting with individuals internally and externally.
Strong independent, critical thinking skills to understand individual and operational problems and identifying appropriate solution(s).
Strong interpersonal, presentation, problem-solving and organizational skills.
Proficiency in Microsoft Office Applications (Word, Excel, PowerPoint, Outlook).
Ability to travel, as necessary, within the designated service area required.
Ability to protect confidential healthcare information and comply with applicable laws, policies, rules and regulations required.
Ability to work independently in Microsoft Office applications with little to no training required.
Ability to demonstrate/express empathy and compassion verbally/telephonically.
Ability to assess needs and design, develop, and implement goal-oriented care plans.
Ability to work in a fast-paced environment with changing priorities.
Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions.
Strong understanding of HEDIS measures and technical specifications preferred.
Demonstrate skills and experience in the field of medical records abstractions, claims coding, education, and training preferred.
Bilingual a plus.
Skills
• Active Listening
• Analytical Decision Making
• Analytical Problem Solving
• Business Compliance
• Collaborative Communications
• Continuous Learning
• Coordinating Resources
• Critical Thinking
• Cross-Functional Communications
• Cross-Functional Planning
• Data Analysis
• Data Management
• Document Recording
• Educational Development
• Interpersonal Relationship Management
• Oral Communications
• Researching
• Strategic Planning
• Time Management
• Written Communication
Responsibilities
• Assists in creating member and practitioner educational materials related to quality management activities and program information.
• Assists in the implementation of new or ongoing quality improvement initiatives.
• Builds strong relationships and serves as an effective liaison and advocate between members, network providers, city and/or county health departments and community service organizations.
• Conducts an in-depth review (retrieval, abstraction, and overread) of clinical medical record documentation for support of HEDIS® audit activities as well as quality gap provider initiative programs ensuring accuracy & compliancy with CMS guidelines for quality initiatives.
• Develops work and progress plans for members based upon interactions and insights gained
• Helps members schedule needed appointments for care and helps members navigate the complex healthcare delivery system.
• Identifies and triages to appropriate health care resources, care coordination, assistance with medical care questions, and resolution of barriers that may prevent effective use of health care resources.
• Measures, analysis, and reports on HEDIS® quality initiative results; collaborating to create necessary tools to capture & report relevant information in identifying member/provider quality gap trends.
• Other activities and projects as directed by the Clinical Quality & HEIDS Leadership team.
• Performs telephonic outreach and health coaching to members and families for medication adherence or preventive care (e.g., BCS/COL) reminders/reinforcement and other Stars measures to improve overall member experience and ensure barriers to care are removed.
• Responsible for assessing and evaluating the member’s need for services and guiding members toward maintaining optimal wellness and care through use of motivational interviewing techniques and advocacy.
• Supports provider outreach initiatives (e.g., sending out gap reports, chasing medical records).
• Works directly with other Stars Member Outreach Specialists, Stars Improvement Nurses, and health plan staff to monitor the gap closures and improvement activities.
Certifications
Security Requirements
This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.
Segregation of Duties
Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.
Employment Type
Regular
ADA Requirements
1.1 General Office Worker, Sedentary, Campus Travel - Someone who normally works in an office setting or remotely and routinely travels for work within walking distance of location of primary work assignment.