Quality Analyst - Area Sur

Blue Cross and Blue Shield Association • Guaynabo, PR

345d

About The Position

At Grupo Triple S, we are committed to provide meaningful job experiences for Valuable People (Gente Valiosa). We encourage an environment of very high ethical standards, always excelling in service, collaboration among the company, agility to deliver timely, and embracing accountability for results. When you join Grupo Triple S, you will be key to our efforts on delivering high-quality and affordable healthcare as well as contribute to our purpose to enable healthier lives. We serve more than 1 million consumers in Puerto Rico through our Medicare Advantage, Medicaid, Commercial, Life and Property & Casualty Businesses. Let's build healthier communities together, join now!

Requirements

• Bachelor's degree in Nursing or Healthcare field with 1 to 3 years of experience in the Health Insurance Industry, preferable.
• Or Associates Degree (60-64 college credits) in Nursing or Healthcare field with 3 to 5 years' experience in the Health Insurance Industry, preferable.
• Or 5 years of experience in the Health Insurance Industry in lieu of a degree.

Responsibilities

• Monitors quality healthcare standards and performance improvement based on regulatory requirements, HEDIS measures and NCQA standards across all organizational areas, including beneficiaries, providers and delegated entities.
• Evaluate primary care physician and participating providers to determine the level of compliance with HEDIS measures.
• Participates in educational and training strategies with providers and Organizational Areas to achieve Quality goals.
• Coordinates and performs medical record revisions in order to collect clinical evidence for gap closure.
• Develop and facilitate implementation of required action plans.
• Responsible for preparing and submitting reports within timeframes.
• Discuss the results of quality evaluations related to HEDIS measures, develop a plan of action and follows up.
• Provide feedback to clients as needed.
• Supports personnel and clients to evaluate and improve effectiveness of healthcare services.
• Conduct weekly, monthly, quarterly and annual reports of activities.
• Keep evidence of all interventions done.
• Understands healthcare standards of care and clinical best-practices to monitor compliance.
• Promotes policies and procedures following recognized standards of care, accreditation, compliance standards and guidelines, and other evaluating entities, including state and federal agencies.
• Participates in proactive team efforts to achieve departmental and company goals.
• Assists and collaborates in strategies to achieve goals for CMS Quality and Star Rating.
• Apply basic knowledge in order to elevate report to next level if required.
• Cross training within the Department.
• Contribute and cooperate in any business matter related to the Quality and Stars Department.
• Maintains a professional, organized and clean work environment by following organizational policies and procedures. Performs other duties as assigned by supervisor.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Religious, Grantmaking, Civic, Professional, and Similar Organizations
• Education Level: Bachelor's degree