Job Summary
Provides senior level clinical support to quality team - contributing to quality improvement programs, initiatives, audits, and quality improvement surveys and federal/state quality compliance activities. Contributes to overarching strategy to provide safe, efficient and cost-effective member care.
Essential Job Duties
- Provides project, program, and/or initiative related guidance to professionals within the quality department, and works collaboratively with other departments.
- Implements key quality strategies that require a component of near real-time clinical decision-making; these activities may include initiation and management of interventions (e.g., removing barriers to care), preparation for quality improvement compliance surveys, review of potential quality of care and critical incident cases, review of medical record documentation for credentialing, model of care oversight, and any other federal and state required quality activities.
- Monitors and ensures that key quality activities that involve clinical decision-making are completed on time and accurately; presents results to key departmental leadership and other departments as needed.
- Writes narrative reports to interpret regulatory specifications, explain programs and results of programs, and document findings and limitations of department interventions.
- Creates, manages, and/or compiles required documentation to maintain critical quality improvement functions with applicable component of clinical decision-making.
- Leads quality improvement activities, meetings, and discussions with other departments within the organization.
- Supports quality activities/initiatives where clinical expertise is applicable/relevant.
- Raises any gaps in processes to leadership that may require remediation; may be asked to focus on parts of the process where a clinician's perspective would be valuable to uncover process gaps or limitations.
- Performs lead role in the coordination and preparation of the Healthcare Effectiveness Data Information Set (HEDIS) medical record review, which includes ongoing review of records submitted by providers and the annual HEDIS medical record review.
- Participates in meetings with vendors for the medical record collection process.
- Assists leadership in quality related training, and demonstrates a lead role in these activities.
- Collects medical records and reports from provider offices, loads data into the HEDIS application, and compares the documentation in the medical record to established specifications to determine if preventive and diagnostic services have been correctly performed.
- Works with the corporate HEDIS team to monitor accuracy of abstracted records as required by specifications.
- Participates in scheduled meetings with the corporate HEDIS team, vendors and HEDIS auditors.
- Assists quality improvement staff with physician and member interventions and incentive efforts as needed through review of medical records documentation.
- Provides data collection and report development support for quality improvement studies and performance improvement projects.
- Assists as needed in support of accreditation activities such as National Committee for Quality Assurance (NCQA) reviews, Consumer Assessment of Healthcare Providers and Systems (CAHPS), and state audits by reviewing clinical documentation.
Required Qualifications
- At least 3 years experience in health care, with a minimum of 2 years experience supporting quality improvement initiatives, preferably in a managed care setting, or equivalent combination of relevant education and experience.
- Registered Nurse (RN). License must be active and unrestricted in state of practice.
- Quality auditing, peer review, and process improvement experience.
- Knowledge of Healthcare Effectiveness Data Information Set (HEDIS) and National Committee for Quality Assurance (NCQA).
- Strong attention to detail, critical-thinking, and problem solving skills.
- Ability to work cross-collaboratively in a highly matrixed organization.
- Time-management skills and ability to multi-task.
- Excellent verbal and written communication skills.
- Microsoft Office suite/applicable software program(s) proficiency.
Preferred Qualifications
- Certified Professional in Health Quality (CPHQ), Certified HEDIS Compliance Auditor (CHCA) or Registered Health Information Technician (RHIT), with training in coding procedures (as required by state/location only), or Certified Professional Coder (CPC).
- Medical coding experience.
- Medical record abstraction experience.
- Managed care experience.
- Ability to work across all levels of the organization, including working with executive audiences, vendors, providers, and the government as a customer.
Pay Range: $49,430.25 - $100,098.87 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.