The primary purpose of the job is to:
This position is responsible for leading and coordinating the clinical quality review process of member concerns and medical records utilizing of care standards. In addition, responsibilities also include supporting the annual medical record review activities including HEDIS and, Clinical Practice Guidelines. The position also supports accreditation and clinical quality performance improvement
1. Assumes responsibility for reviewing all sentinel events and member concerns reported for potential quality of care issues. Coordinates reviews with physician advisors and clinical quality committees as appropriate.
2. Assures minimally necessary medical records are collected and organized for clinical review to occur. Summarizes all clinical findings for review by clinical committees as appropriate.
3. Prepares meeting packets, schedules meetings, develops agendas, completes minutes, and chairs the Internal Quality Review Committee (IQRC).
4. Maintains database to support trending and reporting of adverse outcomes resulting from clinical care provided.
5. Develops reports and analysis for semi-annual trending reports and presents to the Quality Medical Management Committee (QMMC) for input and direction. Follows up on any recommendations.
6. Maintains QR policies including annual reviews, updates, and approvals.
7. Maintains hard copy documentation in accordance with contractual requirements.
8. Conducts analysis annually on the Plan's efforts to improve the safety of members.
9. Supports the quality improvement department with annual medical record review activities including HEDIS, Healthy Kentuckians, and Clinical Practice Guidelines by working collaboratively with the Quality Improvement Department. Assistance will be based upon the organizations needs annually but may include participation in the development of medical record review tools, conducting training and testing of medical record review staff, and auditing medical record reviews upon completion.
10. Performs other related duties and special projects as assigned.
11. Supports and carries out Passport Health Plan's and Passport Advantage's Mission and Values.
3 – 5 years Managed Care experience
Proficient with Microsoft Office applications including Word, PowerPoint, Excel required
Knowledge and understanding of QI functions in an MCO preferred
Knowledge of Medicaid and Medicare preferred
3-5 years quality improvement experience required
2-4 years experience in project facilitation/management role
• Excellent written and verbal communication skills
• Ability to positively interact and work collaboratively with varying levels of education and background
• Ability to organize multiple projects while adhering to objectives and timelines
• Ability to function independently with little or no supervision
• Ability to incorporate Mission and Values into job performance and duties
Healthcare Effectiveness Data And Information Set