Registered Nurse
3 weeks ago
Job Purpose:
This position is responsible for conducting data collection and abstraction of medical records for HEDIS and Quality projects including supplemental data collection. Responsible for interacting with various internal staff, internal departments, and network providers/IPA’s to ensure quality performance and results for the company's managed care products. Responsible for auditing all aspects of company clinical quality improvement projects and evaluating PCP/MG/IPA compliance with company clinical practice guidelines. Also responsible for data analysis, interaction with providers. Practices and IPAs to educate on HEDIS measures, gaps in care and quality programs. Translate data into actionable information and determine areas for improvements as well as help implement actions toward improvement and report results to internal and external customers.
DUTIES AND RESPONSIBILITIES:
- Interact with various internal departments, network practitioners, and MG/IPAs to ensure quality for the company's managed care products.
- Responsible for auditing, analysis of clinical data, and interaction with providers to translate data into information, determine areas for improvement, and help implement actions toward improvement.
- Conduct audits for HMO Clinical Quality Improvement Projects.
- Analyzes data and creates reports for statistically significant random samples regarding interrater reliability.
- Reports findings to project-specific workgroups and management.
- Identifies opportunities for improvement. Assists with implementation of corrective action plans. Re-audits to evaluate effectiveness of interventions.
- Develop reports and presents findings to QI, Workgroups, as well as the Managed Care Quality Improvement Committees regarding HMO, PPO/FEP and POS quality improvement issues.
- Perform quantitative and qualitative analysis for HMO and POS Clinical Quality Improvement projects.
- Creates detailed Quality Improvement Activity reports required for NCQA accreditation, evaluates outcomes, works with Quality Management Specialists to determine opportunities for improvement, and helps implement actions toward improvement.
- Documents actions taken for improvement and measures the impact of interventions to determine if changes or improvements are statistically significant.
- Conduct formal presentations, reporting results from oversight of delegated Behavioral Health continuity and coordination performance Medical Management audits, HMO Clinical Quality Improvement QI Fund Projects, and provider appeal data analysis at project-specific, HEDIS and Quality Improvement Workgroups.
- Perform onsite and concurrent audits for HEDIS Effectiveness of Care clinical indicators during data abstraction process, evaluate interrater reliability through analysis of employee-specific results, reports results to staff and management, assists with re-training employees on areas with identified deficiencies and evaluating the effectiveness of re-training.
- Communicate and interact effectively and professionally with co-workers, management, customers, etc.
- Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
- Maintain complete confidentiality of company business.
- Maintain communication with management regarding developments within areas of assigned responsibilities and perform special projects as required or requested.
QUALIFICATIONS:
- Registered Nurse (RN) OR licensed clinician with current, unrestricted license in MT
- Minimum of 3 years of clinical practice experience performing HEDIS medical record review
- Minimum of 3 years of Healthcare or Managed Care experience, including quality improvement and/or project management experience
- Minimum of 1 year HEDIS medical record data abstraction
- Working knowledge of managed care programs and NCQA and/or URAC Accreditation guidelines
- Project management experience and skills
- Data analysis experience, skills and knowledge of statistical analysis software, and statistical methods and meaning knowledge
- Ability to adapt to changing priorities and managing a wide range of quality projects
- Able and willing to travel
- Verbal and written communication skills
- Problem resolution skills and ability to work with difficult situations with respect and diplomacy
- Presentation planning and delivery experience for provider training
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