Required Skills & Experience
Experience supporting HEDIS, Stars, and healthcare quality improvement initiatives. Strong understanding of Medicare Advantage Risk Adjustment.
Ability to confidently discuss:
CMS risk adjustment programs RAF/HCC concepts Coding capture and documentation best practices Submission and reconciliation processes Experience working directly with physicians, provider offices, or healthcare practice leadership. Strong analytical skills with the ability to interpret dashboards and performance data. Ability to independently identify priorities and recommend strategic actions. Excellent communication and presentation skills.
Nice to Have Skills & Experience
CPC, CRC, CCA, or similar coding certifications. Experience in IPAs, MSOs, health plans, or delegated risk organizations. Experience supporting non-integrated provider environments where multiple EMRs are utilized.
Job Description
We are seeking a Quality Improvement Specialist to serve as the primary liaison between an Independent Physician Association (IPA) and its network of primary care providers. This individual will help drive quality performance, HEDIS measures, Stars performance, and Medicare Advantage risk adjustment initiatives across a provider network of approximately 230 PCPs. This is a highly relationship-driven role that combines provider engagement, quality improvement strategy, risk adjustment expertise, and data-driven decision making. The ideal candidate can confidently engage physicians, translate data into actionable insights, and influence performance improvement across diverse provider organizations.
Key Responsibilities:
Act as the primary quality improvement resource for assigned PCP practices within the IPA. Educate providers and office staff on HEDIS measures, Stars performance, and Medicare Advantage risk adjustment programs. Conduct provider performance reviews and develop improvement plans based on quality metrics and risk adjustment opportunities. Analyze quality and risk adjustment data, identify trends, and prioritize high-impact opportunities. Partner directly with physicians, office managers, and practice staff to drive quality outcomes. Present performance results, quality gaps, and improvement recommendations to providers. Serve as a trusted advisor and subject matter expert for risk adjustment and quality initiatives. Support chart review activities, documentation improvement efforts, and coding-related education. Balance field-based provider engagement with remote planning, analysis, and meeting preparation. Collaborate closely with the existing Quality Improvement Specialist to divide provider coverage and coordinate strategy.
Day-to-Day Breakdown
Approximately:
70% Provider Engagement In-person and virtual meetings with PCPs and office staff Quality improvement planning Provider education and relationship management
30% Data Analysis & Administrative Work Reviewing dashboards and performance reports Identifying actionable opportunities Preparing provider-specific recommendations Scheduling and follow-up activities