Performs tasks associated with quality initiatives to improve member care. Ensures the effective management of care gaps, including data entry, referral tracking and telephonic member and provider outreach. Provides direct supervision for assigned Clinical Quality Specialists.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
· Oversees assigned Clinical Quality Specialists by conducting performance evaluations, communicating team goals and deadlines, and providing training and direct oversight to ensure quality and compliance.
· Coordinates time management for assigned Clinical Quality Specialists including timesheet and absence approvals.
· Supports and maintains outreach initiatives with members and providers.
· Effectively educates providers on quality metric guidelines to enhance patient compliance.
· Oversees assigned geographic area for scheduling record audits at remote provider offices.
· Conducts record audits at remote provider offices.
· Performs accurate data entry in HEDIS software system and outreach tracking system.
· Reviews and maintains medical records to identify, confirm, and/or document referrals, results, and appropriate medical coding.
· Maintains detailed technical understanding of HEDIS, CAHPS, HOS, and Meaningful Use measures set by CMS performance standards
· Must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy.
· Performs other duties as assigned.
EDUCATION AND EXPERIENCE:
· High School diploma or equivalent required
· Current Certified/Registered Medical Assistant in State of Oklahoma and one year of experience with a health plan or within a quality department or clinical setting required. Will consider an additional 6 months of experience with a health plan or within a quality department or clinical setting in lieu of Certification.
· Previous supervisor or lead experience preferred
· Associate degree or equivalent coursework completed preferred
· Valid state Driver’s License, reliable personal vehicle and proof of personal vehicle liability insurance required.
KNOWLEDGE, SKILLS AND ABILITIES:
· Computer literate and familiar with Microsoft applications (Word, Excel)
· Basic electronic health record knowledge and ability to quickly learn new software
· Detailed knowledge of quality performance measures and clinical health care
· Strong organizational and time management skills
· Strong verbal and written communication skills
· Ability to effectively manage a team, including defining and setting priorities
Prolonged sitting at a desk using telephone and computer. Frequent and repetitive keyboard use. Work involves standing and walking for brief periods of time. Work requires normal vision and hearing as might be required in typical conversation use and to operate a computer. Must be able to read, write, and speak English. May need to lift up to 25 pounds. Possible exposure to bodily fluids in a medical clinic setting.
Travel required up to 75% of the time January – June. Occasional travel required outside of audit season. Overnight stays possible.
Supervises work of others, including planning, assigning and scheduling work, reviewing work and ensuring quality standards, training staff and overseeing their productivity. May offer recommendations for hiring, termination and pay adjustments, but does not have responsibility for making these decisions.
This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.