Martin's Point Health Care

Reviewer

• Performs clinical chart reviews and audits to ensure accuracy and compliance with HEDIS measures.
• Develops reports to identify HEDIS care gaps and trends and works closely with providers to ensure the necessary services are provided and documented according to HEDIS requirements.
• Assists in the coordination of outreach efforts to request, collect, and secure clinical documentation from individual providers or provider groups as indicated by individual HEDIS measure specifications.
• Collaborates with health plan departments to identify HEDIS data sources and develop systems to capture this data in accordance with HEDIS technical specifications, such as supplemental databases.
• Collaborates with data analysts and quality teams to support performance improvement.
• Documents findings and recommends strategies to improve HEDIS measure performance.
• Applies clinical expertise to identify and validate data discrepancies.
• Educates non-clinical staff on HEDIS requirements and clinical relevance of data.
• Corresponds with members and clinical providers to effectively coordinate care, obtain medical records, and ensure patients receive preventive and chronic disease management services.

HEDIS Nurse Reviewer – New England Region

Medical Director

• Manage the Health Plan Medical Directors
• Provide clinical support for the Health Management Utilization Management, Care Management and Quality teams
• Drive the development, promotion and delivery of high quality, evidence-based utilization and care management programs and processes
• Lead programs and reviews to support effective medical expense management, medical quality programs and outcomes, and programs to manage medical utilization trends such as inpatient, Emergency Department, Site of Care, pharmacy and radiology
• Achieves defined clinical outcomes, affordability goals and growth targets
• Works closely across the HP to ensure compliance with government program regulations, including management of clinical appeals and grievances with sound clinical evidence and advice
• Works closely with the Medical Directors and the Director of Medical Economics to devise analytic approaches that support and measure strategic development and sound clinical programs
• Provides clinical insight into data to assist in development of and measurement of tailored interventions that address clinical trends and opportunities
• Develops key strategies to address opportunities in medical expense management
• Identifies opportunities for improvement in the quality of care that create competitive advantage for Martin’s Point as it relates to the health of populations served
• Accountable for appropriate Utilization Management processes
• Assists and provides clinical input into the evolution of care/utilization management, quality, and pharmacy related programs
• Contributes to and advises in product design and the Medicare bid processes
• Contributes to and advises in areas of clinical integration as it relates to risk adjustment
• Serves as a central HP leader aligning medical, clinical, and operational functions to achieve seamless and thorough solutions related to Medical and Payment Policies
• Actively engages with quality, network, and compliance teams to help drive performance

Vice President, Medical Director of Clinical Programs

Business Intelligence Developer

• Leads the migration of legacy reporting platforms (e.g., Cognos, Tableau, SSRS) to Power BI
• Designs and implement robust semantic models and data sets to support self-service analytics and standardized reporting across clinical, operational, and financial domains
• Establishes and enforce Power BI governance standards, including workspace architecture, data security, and lifecycle management
• Partners with data architecture and engineering teams to ensure optimized data pipelines and integration
• Collaborates with clinical, actuarial, and operational stakeholders to define KPIs and reporting requirements
• Mentors junior analysts in best practices in DAX, Power Query, and data modeling
• Monitors and optimizes Power BI performance, including dataset refresh schedules, query tuning, and report responsiveness
• Supports change management and user adoption through training and documentation

HEDIS Nurse Reviewer – New England Region

Vice President, Medical Director of Clinical Programs

Senior Business Intelligence Engineer