Quality Care Improvement Specialist

• Put Patients First
• Empower Entrepreneurial Provider and Care Teams
• Operate with Integrity & Excellence
• Be Innovative
• Work As One Team

What You'll Do

• Build and maintain strong relationships with provider offices and clinic leadership. 
• Conduct onsite and virtual provider outreach visits to review quality performance metrics, identify improvement opportunities, and retrieve relevant care gap closure data/records.
• Collaborate with assigned provider offices and health plans to improve documentation, coding accuracy, and care gap closure. 
• Collect, review, and validate medical records to ensure accuracy and completeness for reporting purposes.
• Educate providers and office staff on quality measures, documentation standards, coding requirements, and best practices. 
• Support monthly supplemental data submission, file preparation, and verification of compliant coding. 
• Work with internal teams and vendors to validate, reconcile, and audit HEDIS records to ensure completeness and accuracy. 
• Assist in developing QI initiatives such as outreach campaigns, provider education, and workflow optimization. 
• Assist practices with workflow optimization, patient outreach strategies, and quality improvement interventions. 
• Serve as a quality performance resource to assigned health plan partners, provider groups, clinics, and MSOs, providing and presenting HEDIS performance scorecards monthly. 
• Monitor HEDIS progress dashboards and address data gaps prior to final submission. 
• Prepare reports, scorecards, and presentations for leadership review. 
• Obtain data needed for Primary Source Verification audits from health plans and vendors and ensure timely submission. 
• Act as a subject matter expert on CMS, HEDIS, NCQA, HIPAA, and health plan standards.
• Conduct comprehensive training for PCPs and specialists on:
  • 1. Quality Measures
  • 2. HEDIS and CMS Star Ratings
  • 3. Performance-Based Incentive Programs
  • 4. Data Accuracy and Documentation Standards
• Perform additional duties and projects assigned.

Qualifications

• Bachelor’s degree or equivalent experience
• 3–5 years of experience in healthcare, ideally in IPA/MSO/Health Plan environments
• Minimum of 1 year of HEDIS-related experience
• Independent transportation and ability to travel up to 25% as needed
• Strong knowledge of managed care and quality program standards
• Excellent analytical, communication, and presentation skills
• Demonstrates initiative, creativity, and a collaborative mindset

• Fluent in Spanish and/or Chinese (Mandarin/Cantonese)
• Familiar with practice management and financial operations
• Are adaptable, self-motivated, and eager to grow within a mission-driven organization
• Highly organized, detail-oriented, and capable of managing multiple priorities in a dynamic environment
• Experienced in outpatient clinical settings 

Environmental Job Requirements and Working Conditions

• The total pay range for this role is $24 - $34 per hour. This salary range represents our national target range for this role.
• This role follows a hybrid work structure where the expectation is to work on the field and at home on a weekly basis. This position requires up to 20%  travel to provider offices in the San Diego area.