Senior Quality Management Coordinator

2 weeks ago

Philadelphia, United States Jefferson Health Plans Full time

Jefferson Health Plans is committed to the development of its staff and the achievement of their career goals. We are hiring a Quality Management Coordinator II to join our team We are committed to creating a community where everyone belongs, acknowledges, and celebrates diversity and has opportunities to grow to their fullest potential.

While this job currently provides a flexible remote option, due to in-office meetings, training as required, or other business needs, our employees are to be residents of PA or the nearby states of DE or NJ.

Working under minimal supervision perform and document quality monitoring, medical record review and focused study activities to measure plan performance with clinical, service, and administrative indicators established by the Quality Management Department, regulatory and accrediting bodies.

As the Quality Management Coordinator II, your daily duties may include:

  • Perform investigations of potential quality of care concerns referred to the QM Department from multiple internal resources and external sources such as but not limited to: UM, Care Management, Complaints and Grievances and Provider Tip Line.
  • Perform quality of care reviews on cases identified as Preventable Serious Adverse Events, based on the CMS / DPW Bulletin.
  • Procure medical records as indicated based on case review.
  • Perform clinical reviews on medical records to verify QOC issues, PSAEs, or payment retractions.
  • Work collaboratively with Claims and Operations and Medical Management to ensure the PSAE review process is seamless and meets with regulatory requirements.
  • Perform medical record reviews and use clinical judgement to determine if issues are identified.
  • Create summaries of medical record reviews and collaborate with Medical Director when indicated. Presents and participates in all applicable cases approved by Senior Medical Director to Credentialing Committee for peer review.
  • Prepare identified cases for internal physician peer reviews and presents cases at credentialing meeting.
  • Prepare cases for external peer review as needed.
  • Maintain timeliness in all case reviews and investigations.
  • Identify opportunities to work with providers to ensure a quality-of-care partnership and act as a liaison for quality and patient safety for par facilities and par providers.
  • Utilize the Healthcare Management integrated software system to build and track cases referred for quality of care, member complaints and PSAEs.
  • Participate in annual required training and competency testing for inters rater reliability.
  • Participate in evaluation process with QM Management Team to identify recommendations for process improvement.
  • Contribute to the development and enhancement of documentation, tracking tools and process flows for quality monitoring and audit activities as assigned by the Management Team.
  • Participate in practitioner medical record review process for HEDIS when indicated, PA Performance Monitoring and other regulatory or QM related activities. Participate in work groups as assigned.
  • Attends inter-departmental meetings alongside QM manager and Director; updates processes and/or workflow activities to departments such as Utilization Management and Complaints and Grievances, and Credentialing Committee.
  • Other duties as assigned.

Qualifications:

  • Graduate of accredited school of nursing, RN
  • 2 years of experience in quality management monitoring activities and/or credentialing/ recredentialing reviews, development, implementation, and evaluation of quality management activities in acute and/or ambulatory health care settings.
  • Managed care experience preferred. Knowledge of medical coding preferred.

Skills, We Value

  • Excellent verbal and written communication skills.
  • Ability to present and discuss clinical quality of care issues with QM Manager and Medical Director.
  • Strong analytical and problem-solving skills.
  • Strong organizational skills and ability to manage multiple priorities.
  • Knowledge of NCQA standards preferred.
  • Ability to function independently with minimal supervision.
  • Basic understanding of QM principles.
  • Basic computer skills in Outlook, MS Word, Excel and Access preferred.

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