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  • Asheville, NC

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RN (Registered Nurse)

Maxim Healthcare Services • Asheville, NC

Posted 1 month ago

Job Snapshot

Other Great Industries
Health Care, Nurse

Job Description

Job Title:

Quality Practice Advisor


Establishes and fosters a healthyworking relationship between large physician practices, IPAs and WellCare.Educates

providers and supports providerpractice sites in regards to the National Committee for Quality Assurance(NCQA) HEDIS

measures. Provides education forHEDIS measures, appropriate medical record documentation and appropriatecoding. Assists

in resolving deficiencies impactingplan compliance to meet State and Federal standards for HEDIS. Acts as aresource for the

market on HEDIS measures, appropriatemedical record documentation and appropriate coding. Supports the developmentand

implementation of quality improvement interventions andaudits in relation to plan providers.

KeyDuties and Responsibilities:

• Advises and educates large Providerpractices and IPAs in appropriate HEDIS measures, medical record documentation

guidelines and HEDIS ICD-9/10 CPT codingin accordance with NCQA requirements.

• Collects, summarizes and trendsprovider performance data to identify and strategize opportunities for providerimprovement.

• Collaborates with ProviderRelations to improve provider performance in areas of Quality, Risk Adjustmentand Operations

(claims and encounters).

• Delivers provider specific metricsand coach providers on gap closing opportunities.

• Identifies specific practice needswhere WellCare can provide support.

• Develops, enhances and maintains providerclinical relationship across product lines.

• Defines gaps in WellCare’s servicerelationship with providers and facilitate resolution.

• Leads and/or supports collaborativebusiness partnerships, elicit client understanding and insight to advise andmake


• Partners with physicians/physicianstaff to find ways to explore new ways to encourage member clinicalparticipation in

wellness and education.

• Provides resources and educationalopportunities to provider and staff.

• Captures concerns and issues inaction plans as agreed upon by provider.

• Documents action plans and detailsof visits and outcomes and reports critical incidents and information regardingquality of

care issues.

• Communicates with external datasources as needed to gather data necessary to measure identified outcomes.

• Provides communication such asnewsletter articles, member education, outreach interventions and providereducation.

• Supports quality improvement HEDISand program studies as needed, requesting records from providers, maintaining

databases, and researching toidentify members' provider encounter history.

• Ensures that documentation producedand/or processed complies with state regulations and/or accrediting body


• Ensures assignedcontract/regulatory report content is accurate and that submission adheres todeadline.

• Participates in and represents planat community, health department, collaborative and other organizationalmeetings

focusing on quality improvement,member education, and disparity programs, as assigned.

• Ensures accuracy in medical recordsfor data collection, data entry and reporting. Enters documentation of findingsin

identified databases.

• Performs other duties as assigned.



Required: A Bachelor's Degree in Healthcare,Public Health, Nursing, Psychology, Health

Administration, Social Work or related field


equivalent work experience of 3 +years directly related HEDIS record collection with

analytical review/evaluation and / orQuality Improvement

Preferred: A Master's Degree in Healthcare,Public Health, Nursing, Psychology, Health

Administration, Social Work or related field


2+ years of experience in directlyrelated HEDIS medical record review and/or Quality Improvement with experiencein data and chart reviews to provide consultation and education to providersand provider staff

1+ year of experience in Managed Care experience

Licensesand Certifications:

One of the following licenses is required:

•        Certified Coding Specialist (CCS)

•        Licensed Practical Nurse (LPN)

•        Licensed Clinical Social Worker (LCSW)

•        LicensedMental Health Counselor

•        (LMHC)

•        Licensed Master Social Work (LMSW)

•        LicensedMarital and Family Therapist

•        (LMFT)

•        Licensed Registered Nurse (RN)

•        Licensed Vocational Nurse (LVN)

•        AcuteCare Nurse Practitioner (APRN)

•        (ACNP-BC)


•        Demonstratedinterpersonal/verbal communication skills

•        Abilityto analyze and interpret financial data in order to coordinate the preparationof financial records

•        Abilityto multi-task

•        Abilityto work in a fast paced environment with changing priorities

•        Abilityto identify basic problems and procedural irregularities, collect data, establishfacts, and draw valid conclusions

•        Abilityto implement process improvements

•        Abilityto effectively present information and respond to questions from families, members,and providers

•        Abilityto influence internal and external constituents

•        Demonstratedanalytical skills

•        Demonstratedcustomer service skills

•        Abilityto analyze and interpret financial data in order to coordinate the preparationof financial records

•        Demonstratedorganizational skills

•        Knowledgeof healthcare delivery

•        Understandingof data analysis and continuous quality improvement process

At Maxim Healthcare Services, we firmly believe that our employees are the heartbeat of our organization and we are happy to offer the following benefits:
  • Competitive pay & weekly paychecks
  • Health, dental, vision, and life insurance
  • 401(k) savings plan
  • Awards and recognition programs 
*Benefit eligibility is dependent on employment status. 

Maxim Healthcare Services is a leading provider of home healthcare, medical-related staffing, travel nursing, and population health and wellness services across the United States. As an established community partner, we have been making a difference in the lives of our employees, caregivers, and patients for more than 30 years. Our commitment to customer service, improving patient care, and staffing experienced healthcare professionals has paved the way for many rewarding career opportunities in the healthcare industry.  

Maxim Healthcare Services, Inc. is an Affirmative Action/Equal Opportunity Employer
Job ID: 461129
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