Karleigh Hoss, took some time out during a busy HEDIS season to tell us all about what she does as an Expert Analyst for Advantasure’s HEDIS Performance Improvement team. If you ask her what she does every day, jokingly, she might say, “everything” and in reality, her role could be considered a “catch all” for client needs. To simplify that, Karleigh acts in a variety of roles: client liaison, investigator and auditor.
“Since its HEDIS MRR (Medical Record Review) season, a team of us are completing the yearly audit to ensure health plans are operating above standard,” said Karleigh. “This also means, we’re meeting with clients, conducting investigations, reviewing records, pulling together client decks and reports, and answering client questions.”
Regulated by NCQA, HEDIS, or Health Effectiveness Data Information Set, is a set of measures that are used to evaluate the quality of care provided by a health plan. CMS implemented the use of HEDIS to score health plans on the quality of care they provide to their members. For Medicare plans, HEDIS scores impact a health plan’s overall Star Rating. This rating allows consumers to compare plans and choose the best option. Furthermore, the higher a Medicare plan’s HEDIS scores are, the higher their Star Rating will most likely be, and the more likely consumers will choose that health plan.
“Throughout the two-and-a-half-month audit process, we work with our clients to help them improve their HEDIS scores in hopes that it will improve their overall Star Rating,” she said. “Essentially, what we’re doing is making sure health plans have done a good job at closing the gaps in care for their members.”
In addition to HEDIS, the work Karleigh does also impacts the Medicare Star Ratings program.
“There is a lot of overlap with HEDIS and the Medicare Star Ratings program because we’re capturing the same measures, however, the specifications for each might be slightly different,” she said. “Whatever we capture through HEDIS is still closing Star gaps, so the better we do during HEDIS MRR, the better the outcome for Star Ratings.”
Karleigh can’t pinpoint one specific golden nugget that she lives by, but she notes that she’s inspired most when she can see the light at the end of the tunnel.
“When things finally take shape and come together, I know that my hard work has paid off,” she said. “I live by the mantra ’hard work pays off’ and I’ve tried to maintain that throughout my career and life.”
While navigating through a uniquely challenging time, it’s important to have an outlet. When she’s not working, Karleigh centers herself by practicing yoga.
“Yoga is my go-to for a favorite hobby,” she said. “It really helps me relax and recharge.”
Recently, Karleigh received an EMMY award for her integrity. Ironically, that’s also a trait she’s most proud of.
“Integrity seems to be undervalued or taken for granted these days” she said. “When others define my character, they highlight my integrity and I’m pretty proud of that.”
When she’s not working or doing yoga, she’s enjoying life as a newlywed and being a fur parent to her dog, Honey.