Under the direction of the QI Manager, performs reviews of health plan data related to the quality of clinical performance and outcomes.
Performs medical record reviews to assess quality of medical record keeping and potential clinical quality issues. Participates in the annual HEDIS hybrid measure data collection through record abstraction and over-reads of abstracted records.
Primary Duties, Responsibilities & Competencies:
Required Competencies and Qualifications:
- Participates in the development and production of quality improvement activities, clinical studies, surveys, and audits/reviews through:
- The timely and accurate collection, data entry, tabulation, and reporting of clinical data, in accordance with AlohaCare policies and procedures;
- Assisting with diagramming Health Plan QI activity processes and workflows, conducting barrier/root cause analysis, and identifying interventions for improvements;
- Assisting with preparation of QI activity reports to internal committees and external entities per Plan’s specified reporting requirements and frequencies
- Performs clinical review of potential quality of care issues that are referred to QI Department for investigation/resolution and refers issues to QI Manager, QI Sr. Director and/or Medical Director for review and action, as appropriate.
- Assists with provider training and education in standards, policies, procedures, programs, resources, etc. related to AlohaCare’s Quality Improvement activities.
- Assists with orientation and training of new QI Department employees in medical review functions and processes.
- Assists in audits of entities with delegated medical records review responsibilities, documenting results and providing written feedback. Where corrective action needed, monitors adequate resolution by delegated entity.
- Conducts reviews of network providers’ medical records against established documentation standards, scoring results, documenting results in database and provider QI file, and providing written feedback of results with any recommendations for improvement to providers. Follows up on resolution of any corrective actions requested.
- Participates in the annual HEDIS® reporting process, including overseeing and/or performing medical record request and initial review, abstraction, over-read functions, and consolidation/finalization of reviews.
- Performs medical record review for various other QI processes as needed.
- Intermediate computer PC skills, including the use of Microsoft Office software
- Strong interpersonal communication skills and ability to interact effectively with health care providers, government agencies, external auditors, sub-contractors, and internal staff.
- Ability to work independently with minimal supervision.
- Strong organizational skills with ability to multi-task
- Current valid State of Hawaii Drivers License
- Able to travel locally on frequent basis, with occasional inter-island travel possible.
- Other job related duties as assigned by the Quality Improvement Manager.
Preferred Competencies and Qualifications:
- RN with current Hawaii license.
An Equal Opportunity Employer
- Minimum three years clinical experience; experience in an acute care setting desirable.
- Knowledge of QI/QA principles and methodology, health care/social research methodology, and ICD-9 and CPT codes desirable.
- Previous experience in a managed care environment desirable.
AlohaCare - 7 months ago