Quality & Risk Adjustment Specialist

Location : Avera Health Plans

Worker Type : Regular

Work Shift :

Day Shift (United States of America)

Pay Range :

The pay range for this position is listed below. Actual pay rate dependent upon experience.

$20.50 - $27.00

Position Highlights

Monday- Frida 8 : 00am-5 : 00pm; 80 hours 2 weeks

No weekends

You Belong at Avera

Be part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. Work where you matter.

A Brief Overview

Responsible for activities focused around Risk Adjustment (RA) initiatives and Healthcare Effectiveness Data Information Sets (HEDIS). The Quality and Risk Adjustment Specialist will work closely with the Director of Quality and Risk Services, Manager of Risk Adjustment, Manager of Quality, Quality Coordinator - HEDIS, coder(s), claims staff, and primary care & specialty care providers to ensure that proper clinical documentation. The QRA Specialist will be responsible for ensuring that medical records for identified members are retrieved, reviewed and documented appropriately for all Quality and RA initiatives.

What you will do

Understand the rationale behind Risk Adjustment Work with physicians, clinic staff, coding, and other Health Plans staff to resolve coding or work process issues in regards to RA.

Supports clinic RA visits & audits.

Responsible for ensuring appropriate parties complete designated RA tasks General understanding of Hierarchical Condition Coding Oversight of External Data Gathering Environment (EDGE) submission process.

Observes, investigates, and reports any trending issues which may cause quality or RA gaps.

Expand job related knowledge through participation in approved continuing education and in-services, including offsite meetings and webinars, in regards to Risk Adjustment and HEDIS.

Supports annual RADV (Risk Adjustment Data Validation) audit with multiple Health Plans departments.

Participates in HEDIS abstraction efforts in collaboration with Quality Coordinator - HEDIS.

Supports member and provider outreach initiatives to close quality and RA gaps.

Identifies opportunities for synergies related to medical record review and manages the medical record request process for Quality and RA.

Essential Qualifications

The individual must be able to work the hours specified. To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge, skills, and abilities required to perform the essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions, as long as the accommodations do not cause undue hardship to the employer.

Required Education, License / Certification, or Work Experience :

• 4-6 years professional experience in insurance or managed care industry.

Preferred Education, License / Certification, or Work Experience :

Expectations and Standards

Commitment to the daily application of Avera's mission, vision, core values, and social principles to serve patients, their families, and our community.

Promote Avera's values of compassion, hospitality, and stewardship.

Uphold Avera's standards of Communication, Attitude, Responsiveness, and Engagement (CARE) with enthusiasm and sincerity.

Maintain confidentiality.

Work effectively in a team environment, coordinating work flow with other team members and ensuring a productive and efficient environment.

Comply with safety principles, laws, regulations, and standards associated with, but not limited to, CMS, The Joint Commission, DHHS, and OSHA if applicable.

Benefits You Need & Then Some

Avera is proud to offer a wide range of benefits to qualifying part-time and full-time employees. We support you with opportunities to help live balanced, healthy lives. Benefits are designed to meet needs of today and into the future.

PTO available day 1 for eligible hires.

Up to 5% employer matching contribution for retirement

Career development guided by hands-on training and mentorship

Avera is an Equal Opportunity Employer - Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, Veteran Status, or other categories protected by law. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-605-504-4444 or send an email to talent@avera.org .

At Avera, the way you are treated as an employee translates into the compassionate care you deliver to patients and team members. Because we consider health care a ministry, you can live out your faith, uphold the dignity and respect of all persons while not compromising high-quality services. Join us in making a positive impact on moving health forward.

The policy of Avera to provide opportunities for all qualified employees or applicants without regard to disability and to provide reasonable accommodations for all employees or applicants who may be disabled. Avera is committed to ensuring compliance in accordance with the Americans with Disability Act. For assistance, please contact HR Now at 605-504-4444.

Additional Notices : For TTY, dial 711

Avera is an Equal Opportunity / Affirmative Action Employer : Minority / Female / Disabled / Veteran / Sexual Orientation / Gender Identity.