JOB SUMMARY

Reports to Director of Quality and Health Plan Compliance. Works independently and with other departments and/or vendors to ensure clinical potential quality issues are tracked, investigated and resolved in accordance with TRICARE and Plan requirements. Primarily responsible for conducting post-service in-depth clinical reviews (both inpatient and ambulatory medical services) in accordance with accepted standards of care. The overall goal is to improve clinical service delivery and organizational processes. RESPONSIBILITIES

Clinical Review

· Utilizes clinical expertise to conduct clinical case retrospective reviews to determine deviation from standard of care or gaps in care and presence of mandatory data elements. Document progress of investigation and findings in internal databases and/or Excel spreadsheets.

· Conduct clinical literature reviews and summarize findings.

· Contact providers/facilities, as applicable, to obtain information and/or medical records needed to conduct a comprehensive clinical review of cases and final determinations.

· Conduct chart reviews and audits both electronic and at medical facilities and providers’ offices. Abstracts data relevant to review target.

· Write succinct and targeted investigative summaries.

· Write determination letters.

· Maintain positive working relationships with internal and external clinical/administrative personnel.

· Maintain confidentiality of all medical records, correspondence and related documents.

· Effectively meets strict deadlines.

Reporting

· Participate in collection and analysis of data for clinical CDRLs reports (i.e., monthly quality issue report, semi-annual AHRQ PSI report, annual clinical quality management program report).

· Participate in collection, analysis and presentation of data for Peer Review, Credentials Review and Quality Committees.

Continuous Quality Improvement

· Participate in continuous quality improvement activities/root cause analysis to resolve identified quality issues and ensure forward movement in beneficiary service delivery.

Performs other duties as assigned or required. Attends meetings to achieve departmental/organizational goals and objectives.
EXPERIENCE
Minimum 5 years of healthcare quality management experience and minimum 5 years clinical nursing experience. Quality assurance/improvement experience in a managed health plan, integrated health care system, or health care accreditation or regulatory agency.

Skills/Competencies

· Ability to read, abstract and analyze medical records as well as other clinical data.

· Analytical mindset with excellent organizational and problem solving skills.

· Ability to work both independently and as a team member.

· Strong project management skills.

· Intermediate statistical analysis expertise including interpretation of data.

· Outstanding communication and interpersonal abilities.

· Manages assigned caseload in accordance with established performance metrics.

· Understanding of medical terminology, anatomy, physiology and concepts of disease and health. Fundamental knowledge of ICD-10, CPT and HCPCS coding.

· Understanding of Medicare, Medicaid and/or TRICARE.

· Proficient in Microsoft Office, including but not limited to Excel, Outlook, PowerPoint and Word. Experience in Access and Visio a plus. Ability and inclination to adopt technology to maximize efficiency

· Ability to travel up to 10% regionally (NY, NJ, PA and CT). Valid driver’s license and/or dependable transportation necessary.

· Decision making: Identification of clinical quality issues as evidenced by deviation from accepted standard of practice or gap in care. Ability to recommend corrective actions and/or sanctions.