JOB SUMMARY

Accountable for planning, developing, executing, and implementing activities which contribute to complying with the HEDIS Technical Specifications, Stars Technical Notes as well as ASES benchmarks. Accountable for the monitoring of all Alianzas Star Ratings Program and PMGA Quality Program work plan towards improvement. Serves as a key contact between Alianzas, PMGA and Triple-S administrative staff representing the HEDIS and Star Ratings Department providing education to increase the Alianzas, PMGA, physicians, and ultimately the health plan’s Star Rating and benchmarks. Will influence Alianzas, PMGA, providers, and administrative staff to implement strategies towards HEDIS, Starsand CAHPS measures improvement and ASES benchmarks. Monitors quality healthcare standards and performance improvement based on regulatory requirements, HEDIS and Star Ratings measures and ASES benchmarks. Performs independently, tasks requiring application of policies and procedures and general methods of operation. 

ESSENTIAL FUNCTIONS

• Evaluates data on a weekly basis, or as needed, according to assigned tasks and, or projects to determine member compliance with Star Rating measures and share results with providers and Alianzas for measure improvement providing leadership and offering possible courses of action for the implementation of targeted work plans focused on improvement and compliance.
• Evaluates data monthly, or as needed, according to Anejo 19 assigned tasks and, or projects to determine quarterly members compliance changes and share results with PMGA for measure improvement providing leadership and offering possible courses of action for the implementation of targeted work plans focused on improvement and compliance.
• Responsible for HEDIS and Stars measure educational interventions to Providers, administrative staff, and Alianzas and PMGA´s to increase their individual improvement. Stars and Plan Performance Executive will assist Supervisor in the development of training materials, templates, and presentations.    
• Facilitates Alianza´s and PMGA´s work planfor targeted quality activities. Analyzes, monitors, and sends updated data per measure per group and on a member and provider level.
• If required, support Alianzas, PMGA´s and providers offices in medical record review, data collection and data entry towards gap closure. Evaluating primary care physician and participating providers to determine the level of compliance with Star Ratings measures and ASES benchmarks.
• Serve as the initial quality assurance for the weekly data updates related to Star Ratings reports.
  Collecting, complete and accurate data which is documented within medical records for HEDIS measure improvement purposes, reflecting proof of evidence of health care services provided by the Health Plan's provider network.
• Responsible for communicating performance results to Alianzas and PCPs, as needed.
• Identify, analyze, and maintain reports to management patterns and development actions plans. Responsible for implementing and discussing the strategy with the Alianzas. Develop and facilitate implementation of required action plans for Alianzas and provider rating improvement.  
• Responsible for identifying opportunities to implement innovative initiatives to enhance the results for Stars Rating.
• Participate on provider's, Alianzas and others operational areas Department’s meeting, as needed.
• Document initiatives through the established operational tools.
• Keeps evidence of all interventions done.
• Supports management in the development of presentations and reports.

EDUCATION

EXPERIENCE

Bachelor's Degree (BS) in Science, Arts, Business Administration, Health Administration, or related area. At least one (1) to three (3) years of related experience and/or training or preferable in the Health Insurance Industry.

LICENSES AND CERTIFICATIONS

COMPETENCIES