Clinical Performance Improvement Coordinator - BLU00063
DESCRIPTION/RESPONSIBILITIES:
Organize and coordinate activities to ensure full compliance with all regulatory and licensing agencies (e.g., CMS, MDCH, and NCQA) and employer groups relative to medical management activities, including accreditation site surveys and regulatory reviews. Coordinate, facilitate, assess and evaluate improvement initiatives utilizing process improvement methodology.
Provide support in developing and maintaining NCQA accreditation and compliance with regulatory standards. In doing so, coordinates preparation for NCQA and other state, federal and employer group regulatory processes. Responsibility includes summarizing and analyzing accreditation standards and reports, preparation of reports/presentations for BCN committees and leadership and assisting in evaluating strategic initiatives in relationship to new and existing standards. Provide support in developing and administration of delegation oversight agreements for new and existing BCN delegates. Perform file review and audits of delegated entities to identify compliance and non-compliance and develop recommendations for corrective actions. Perform retrospective review to validate clinical criteria and medical necessity requirements, reduce practice pattern variation, identify best practice providers, and monitor billing and reimbursement practices. Prepare quality reports through data collection, data input and report development. Perform quality audits for all Care Management professional team members including nurses and physicians. Provide objective assessment of documentation requirements through ongoing case review. Audit results are compiled, team members are coached based on the audit results, and results are presented to the team leaders. Areas for improvement may be identified which may include training or reinforcement of previously trained materials. Conduct physician advisor quality audits. Compile results and share with the Associate Medical Director. Act as liaison and provide support for the care management leadership team. Assist in development and implementation of policy and procedure, and development of programs. Act as intermediary between internal functional areas and with other departments in relation to care management initiatives. Develops quality improvement activities to prevent occurrence of adverse outcomes, including consistent benefit administration (i.e. timeliness of decision, appeal turnaround, etc.). Serve as customer communication lead for care management. Responsible for the coordination of the care management portion of the Provider Manual and provider newsletter through interface with the corporate provider communication team. Responsible for coordination of care management’s portion of the member newsletter, and external communication tools such as the member handbook and website. Responsible for activities related to the Clinical Quality Committee and Care Management Advisory Council. Assists in development of agenda, completes quality review of materials, and participates in committee meetings. Acts as a liaison within the care management department to coordinate agenda topics, and obtain necessary reports and materials from various function areas and departments company-wide. Conduct quality improvement studies for Care Management to assist in identification of quality variances, including over and under utilization. Investigate and analyze quality related issues/incidents reported by internal team members, members or providers, which may result in less than optimal quality of care for BCN members, adverse exposure or potential legal risk for the corporation. Assist in crisis management of unusual consequences which result from member, employer group or provider dissatisfaction. Acts as a liaison to Quality Management, Provider Services, Customer Services, Corporate Communications, senior leadership and legal counsel. Coordinate written responses to RFI’s. Measure Care Management’s compliance with customer expectation. Develop and implement corrective action plan to meet or exceed customer expectations. Provide recommendations based on analysis. Responsible for oversight of HEDIS initiatives assigned to care management. Provides oversight of process to improve HEDIS rates related to above. Responsible for the monitoring and oversight of member satisfaction for the department. Acts as department liaison related to the company’s CAHPS workgroup. Promote and engage in positive and constructive daily team work, participate in after hours call schedule and perform other duties as needed. Work with an inter-disciplinary team including members of Quality Management, Provider Services and Customer Services improve quality-related issues.
All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, protected veteran status or status as an individual with a disability.
