AI use among medical and health services managers is little observed so far. Measured exposure for medical and health services managers: 7% (little observed).

Share of this job’s tasks that AI is already used for at work, from real usage. It is not a forecast of job loss, and a low number means no use seen yet. Source: Anthropic Economic Index.

Check how this applies to your own job

Skills this job asks for

Say which you have and which you want to build. We use it to match you to jobs like this one.

About the job

The Clinical Quality Manager works with members and providers to ensure members receive appropriate services. This role emphasizes improving the quality of care with a focus on HEDIS, QARR and Medicare Advantage Star measures.

Duties & Responsibilities:

• Interacts with hospitals, providers, and members to improve quality of care, monitor progress, and recommend changes

• Reviews billing codes, medical records, and claims submission processes to ensure accuracy

• Attends and facilitates any initiative meetings (studies, partnerships) that involve targeted providers and/or measures

• Completes on-site provider visits to implement work plans and conduct provider education sessions regarding appropriate coding practices and chart documentation

• Collaborates with other departments to maximize member outreach for preventive services and chronic disease management

• Assists in writing member and/or provider articles on HEDIS, QARR, Medicare Advantage, and/or health promotions for the HF newsletter

• Assists and supports regulatory affairs

• Document all relevant interactions in appropriate systems

• Additional duties as necessary

Minimum Qualifications:

• Associate’s degree from an accredited institution

• Ability to travel around the NYC metro area

Preferred Qualifications:

• Bachelor’s Degree from an accredited institution

• Clinical license: LPN, RN, LMSW or LCSW

• Multiple years of HEDIS review experience for both Medicaid and Medicare lines of business

• Medical record review experience directly working on HEDIS/QARR in a managed care setting

• Good presentation, relationship management, and analytical skills

• Intermediate MS Word, Excel, and PowerPoint

• Compliance & Regulatory Responsibilities: Noted above

License/Certification: N/A

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC.

Know Your Rights

All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $83,100 - $120,360

• All Other Locations (within approved locations): $73,400 - $108,160

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

*The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.