Quality Health Navigator

Summary of Job

Responsible for the application of data analytics to prioritize members with possible gaps in care for the purpose of increasing Medicare Star ratings and Medicaid Quality Incentive scores. Educate members on the importance of routine preventive care as well as maintaining regular appointments for chronic conditions for themselves and/or their children. Increase HEDIS/QARR rates through increased member education and medical care gap closure. Make outreach calls to support the Health Outcomes Survey to discuss fall prevention, physical and mental health outreach.

Responsibilities

• Use analytics to identify Emblem Health members for health education; review members' individual needs related to gaps in care; and community resources to facilitate medical care.
• Refer members to case management as needed and assist members with making appointments.
• Contribute to the ongoing development and advancement of the function's community health strategies and activities.
• Collect, interpret, and disseminate/present data and information related to process and outcomes gleaned from telephone calls in all efforts pertaining to continuous quality improvement.
• Utilize HEDIS checklist in outreach efforts in order to identify gaps in clinical service outcomes.
• Maintain up-to-date knowledge and understanding of HEDIS/QARR/Star measure technical specifications.
• Provide clinical support related to assigned measures.
• Make recommendations on initiatives and outreaches based on knowledge of the specific clinical criteria of the measure.
• Provide information to clinical staff and telephonic outreach to ensure compliance with Clinical Practice guidelines, Preventive Health guidelines.
• Facilitate quality improvement activities to improve the delivery of quality health care to EmblemHealth members.
• Perform other related tasks as directed, assigned, or required.