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Positions Available

Updated March, 2013

Clinical Quality Improvement Analyst

Department: Quality Management

Full-time Position

Reports directly to the Director of Quality Management

Job Responsibilities

  • Conducts onsite medical record review as needed to monitor compliance of medical record documentation, adherence to Clinical Practice Guidelines
  • Conducts onsite facility review for all new providers
  • Conducts onsite facility review for all patient complaints regarding site issues
  • Supports data collection, analysis and submission required for health plan quality improvement monitoring and reporting. HEDIS/CMS Star/P4P,
  • Conducts ongoing analysis and monitoring of QI indicators
  • Assists in the investigation, tracking and trending of all quality of care referrals or adverse events reported to the Quality Department, and provides training to all parts of the organization to correctly identify and refer these occurrences. 
  •  Acts as a clinical resource to non-clinical staff within the Quality Department. 
  • Prepares and disseminates reports, analysis of medical reports and records, database tracking, report generation, training and consultation as needed.
  • Conducts periodic audits/reviews of established quality programs to determine efficiency, adherence to policy and effectiveness.
  • Makes written recommendations for system wide process improvement purposes.
  • Acts as a liaison with other departments to improve health plan processes and implement quality improvement processes.
  • Monitors quality program compliance for all regulatory agencies.
  • Participates in the review and analysis of data from survey tools, including but not limited to, provider satisfaction survey, HOS and PAS surveys
  • Works closely with the QM Director and all departments throughout the Medical Group to communicate and support all Quality Improvement Projects

Skills and Responsibilities

  • This position is multifaceted requiring a diverse set of organizational skills, including, but not limited to, targeted analysis of medical reports and records, database tracking, report generation, training and consultation.
  • Understanding of the managed care industry, including types of managed care customers, clients, and payers. Fundamentals include medical terminology, clinical coding guidelines and regulations
  • The Clinical Quality Improvement Analyst works closely with the QM Director and all departments throughout the Medical Group to communicate and support all Quality Improvement Projects.
  • Requires strong critical thinking skills.
  • Knowledge & understanding of HEDIS & survey protocols and statistical concepts preferred
  • Knowledge of data collection, data analysis and presentation required
  • Excellent interpersonal communication (both oral & written), organizational and problem-solving skills required
  • Ability to understand federal and state laws, contracts and regulations required

Qualifications Experience

  • Current LVN Licensure required.
  • CPHQ highly desirable
  • Minimum of 3 years nursing experience in healthcare setting, hospital or skilled nursing facility
  • Minimum of 1 year medical record review for adverse events or quality of care
  • Experience with HEDIS/STAR  medical record review a plus
  • Participation or experience in data collection and reporting to support health care improvement activities
  • Required software experience:
  • Microsoft Excel (intermediate to advanced user)
  • Microsoft Word (intermediate to advanced user)

Core Competencies

  • Effectiveness in communication style (written and verbal), with advanced grammar comprehension, and proven ability to positively influence behavior toward a positive outcome
  • Conflict resolution skills, and change management skills with the ability to work with and meet deadlines
  • Self motivated with the ability to work independently, as well as within a team environment
  • Strong organizational skills and ability to meet timelines and deadlines
  • Strong computer skills with the ability to type 50 wpm; must be internet literate
  • Ability to adapt and quickly learn electronic  
  • Knowledge of  CMS, HEDIS and NCQA medical record documentation requirements
  • Knowledge of HEDIS medical record collection process
  • Ability to multi-task and work closely with all associated in the delivery of services including: Medical Director, Providers of care, Provider Relations, Compliance, Member Services, Case Management, Utilization Management, Credentialing, Enrollment, Claims, Decision Support and other staff as necessary


Certified Medical Coder

Heritage Victor Valley Medical Group has an immediate need for a Certified Medical Coder. 2+ years as a medical coder, knowledge of Medicare risk adjustment and a certification through the AAPC or comparable organization required.


  • Evaluates medical record documentation and coding to optimize reimbursement and ensure adequate collection of clinical quality data; ensures diagnostic and procedural code and other documentation accurately reflect and support services rendered as well as date comply with legal standards and guidelines; interprets medical information such as disease, symptoms and treatment, and diagnostic descriptions and procedures for a given visit in order to accurately assign and sequence the correct ICD-9-CM and CPT codes and identify all appropriate codes based on CMS HCC categories
  • Provides guidance to primary care site in identifying and resolving issues or errors, such as incomplete or missing records and documentation, ambiguous or nonspecific documentation, or codes that do not conform to approved coding principles/guidelines; educates and advised staff on proper code selection, documentation, procedures and requirements
  • Serve as a resource for primary care site to answer questions regarding risk adjustment and Medicare and Medicaid coding guidelines and updates.
  • 2 plus years experience working in a health care setting
  • Possession of Certified Coding Specialist designation (CCS, CSS, CCS-P or Certified Professional Coder (CPC) from the American Association of professional Coders); or 3 years experience in medical record coding
  • Knowledge of: ICD-9-CM, and CPT coding guidelines; medical terminology; anatomy and physiology; pharmacology; Medicaid and Medicare reimbursement guidelines;
  • Preferred: Knowledge of health care insurance claims practice and compliance
  • Preferred: Familiarity with physician-specific regulations and policies related to documentation and coding
  • Preferred: Knowledge of Medicare risk adjustment documentation requirements
  • Proven experience working both autonomously, as well as, in a team environment
FAX resume to: 760.245.4868
Attention: Human Resources