[Hiring] Clinical Quality Navigator II @Elevance Health

Role Description

The Clinical Quality Navigator II is responsible for ensuring that appropriate clinical data and documentation exists, as well as proactively identifying ways to improve the health of our members and meet clinical quality goals.

• Assesses members’ clinical quality needs and closure status via medical record review, clinical documentation collection or telephone.
• Supports clinical team with resolution of barriers to ensure quality gap closure.
• Support clinical team with member reminders for screenings and tests.
• Coordinates follow-up care plan needs for members by scheduling appointments or enrolling members in programs.
• Coordinates referral to local, state or federally funded programs.
• Identifies opportunities that impact quality goals and recommends process improvements.
• Medical record collection and review to support care plan needs of the member, including but not limited to outreach to other providers or facilities.
• Medical record audit support to support HEDIS/Star program goals.
• Prepares reports to document case and compliance updates.
• Establishes and maintains relationships with agencies identified in appropriate contract.
• Participates in cross-functional teams on projects, initiatives, and process improvement activities.
• Support process improvement through the identification, verification and documentation of data source management processes, as well as development of associated action plans.
• Subject matter expert in HEDIS/Star measures by providing guidance, education/training and support to program team members and clinical care team to ensure compliance with documentation requirements.

Qualifications

• Requires a H.S. diploma or equivalent and a minimum of 3 years of related experience; or any combination of education and experience which would provide an equivalent background.
• Over 2 years of experience in the healthcare industry.
• Proficient in Microsoft Office (Word, Excel, PowerPoint, and Outlook).
• Experience working with clinical systems such as electronic medical records, care management, or population health management.
• Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or detailed information in an understandable manner, and capable of understanding and interpreting complex clinical information from others.
• Certification or licensure in a clinical or healthcare-related field, with at least 2 years of patient-facing experience.
• More than 3 years of experience with electronic medical records, medical records, or patient-facing interaction in any healthcare environment.
• At least 2 years of experience in clinical quality, specifically with HEDIS/Stars.
• More than 2 years of experience in clinical data collection, abstraction, or validation.
• Certified nurse assistant or certified medical assistant and/or a BS/BA degree in a related field is preferred.
• Bilingual candidates are preferred.

Benefits

• Market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs.
• Medical, dental, vision, short and long term disability benefits.
• 401(k) + match, stock purchase plan, life insurance, wellness programs and financial education resources.

Company Description

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.