Job Description

Summary:

The Quality Care Gap Specialist has duties and responsibilities related to closure of preventive care gaps and follow-up patient care needs.  The functions of this position include care coordination, care gap closure, chart reviews, auditing and monitoring of quality initiatives and patient navigation/education.  The Quality Care Gap Specialist conducts outreach to patients who are identified as needing preventive and/or follow-up care services in support of quality initiatives and regulatory/contractual requirements. The Quality Care Gap Specialist provides education to members regarding the need for preventative care. The individual maintains confidentiality of business and protected health information and must be an advocate for the Patient Centered Medical Home.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Communication: Conveys information accurately and efficiently.  Written communication is direct, concise, and easy to understand. 
• Decision-making: Gathers necessary information to make good and timely decisions.  Uses sound judgment and instincts.  Seeks direction from Leadership appropriately.
• Supporting/Assisting:  Seeks opportunities to help others be successful in meeting goals.  Demonstrates behaviors reflective of our mission when helping others.
• Planning/Priority setting: Organizes tasks and objectives in order of importance, timing, and predicted results.  Works within measureable goals and outcomes.
• Problem solving: Works systematically to solve problems.  Develops reasonable and timely resolutions. 
• Initiative: Takes prompt action to accomplish objectives.  Seeks to resolve problems without being asked. Seeks direction from Leadership appropriately.

Key Functions:

• Performing medical record data review/collection as it related to HEDIS measurement and gap closure.
• Resolving clinical quality care gaps related to preventative disease management.
• Collaborating with Payers and Payer Relations staff to work care gap reports. 
• Interacting with the clinical team and outside insurance agencies to identify and resolve care gaps. 
• Knowledgeable of clinical quality measures and preventive health maintenance recommendations.
• Educating patients, family members, and other staff members in these areas as needed. . 
• Understanding and adhering to regulations for FQHCs and Primary Care Centers. 
• Maintaining a comprehensive working knowledge of community resources, payer requirements, and network services for target populations.
• Understanding population health and working collaboratively with the health care team to promote health and wellness.
• Communicating regularly with Quality Manager to provide status of care gaps by payer. 
• Developing strong knowledge of electronic medical record and reporting capabilities.
• Working collaboratively with RN Case Managers and other care team members to identify/address barriers to care.
• Working intimately with IT staff and Patient Care Teams to improve clinical quality outcomes.
• Performing other duties as assigned within scope of practice. 
• Proficiency with Microsoft Office Suite applications.
• Intermediate in excel and spreadsheet data entry.
• Ability to learn usage of video conferencing and online collaborative tools. 

OTHER ESSENTIAL DUTIES and RESPONSIBILITIES:

• Grace Health recognizes that managing patient care is a team effort that involves clinical and non-clinical staff.  All employees must embrace a team-based approach to patient care and understand that each role is important to our success. 
• Team members must demonstrate excellent team communication and coordination to provide quality patient care.
• Care coordination includes communicating with community organizations, health plans, facilities, and specialists.
• Care team members understand and embrace the concept of population management and proactively address the needs of patients and families served by this practice. 
• Team members must demonstrate skill and knowledge related to effective communication with vulnerable patient populations.
• Team members must participate in Continuous Quality Improvement activities within the organization to ensure patients receive high quality care.
• All team members will be involved in the process of improving quality incomes.
• Team members will participate in the review and evaluation processes of practice performance and help to identify opportunities for improvement.
• Team members will participate in Grace Health's advocacy program .

GENERAL DUTIES:

• Follows policies and procedures of the clinic and evidence-based guidelines for patient care.
• Maintains good attendance and adheres to staff requirements outlined in the Employee Handbook. 
• Maintains timely documentation of all work assignments.
• Maintains patient confidentiality at all times.
• Routinely keeps supervisor informed
• Flexible in being able to multi-task
• Work effectively and at an efficient pace
• Work cooperatively with providers, leadership, and other staff.
• Other duties as assigned by manager/director.

QUALIFICATION REQUIREMENTS:  

To perform this job successfully, an individual must be able to assist in advancing Grace Health’s mission and to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

SKILLS:

• Communication
• Computer/Technology
• Conflict resolution
• Customer service
• Team building
• Time management
• Critical thinking
• Leadership

EDUCATION and/or EXPERIENCE: 

High School diploma or GED in general field of study.

Minimum of 2 years clinical experience or managed care/health plan experience.

Fluency in evidence-based care guidelines for disease prevention.

Experience with electronic medical records.

Experience related to quality management/performance improvement preferred.

BENEFITS:

• Safe harbor 401(k) with match potential
• Paid time off
• Family friendly work environment
• Health insurance
  • Wellness program
  • Health savings account
  • Pharmacy benefit
  • Employee visits for medical services
• Dental insurance
• Vision insurance
• Life Insurance
• STD/LTD
• EAP & Work life services
• Voluntary benefits
• Hospital indemnity

Grace Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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