Job Description: Job Summary:
This position is responsible for conducting quality audits for state audits, HEDIS and quality referral and complaints issues.
Responsibilities:
- Conducts on-site/virtual reviews at participating provider offices to assess environment, quality of physicians medical records, and compliance with HEDIS documentation standards.
- Attends HEDIS Measure and QMRM (documenting platform) training and passes with 100% accuracy.
- Assists the Quality Management department with various special projects and focused clinical studies.
- Performs related tasks or special studies as requested.
- Assists in training of, providers on audit standards, off site.
- In-house representative for chart chase audits.
- Produces various reports as requested.
- Reviews supplemental data charts (approx. 50 charts per day) as assigned by team leads. Charts are audited and processed in the format provided through Excel.
- Works with providers to obtain charts for chart chase. Charts are processed and reviewed in a timely manner (24 hours).
Qualifications:
Education/Experience:
- Requires three to five years related business experience, preferably n health care industry.
- Requires License Practical Nurse License or an active New Jersey Registered Nurse License.
Additional licensing, certifications, registrations:
- Requires valid Motor Vehicle driver's license and access to an automobile.
Knowledge:
- Requires knowledge of managed care principles.
- Requires knowledge of medical terminology.
- Requires knowledge of PC's and related software.
- Prefers knowledge of URAC accreditation standards and HEDIS principles.
- Prefers knowledge of health management or patient education.
Skills and Abilities:
- Require excellent verbal and written communication skills.
- Requires excellent organization skills.
- Require strong analytical skills.
- Requires good problem solving/conflict resolution skills.
- Requires good decision making skills.
- Requires strong PC skills.
- Require strong presentation skills.
Supplier Call Notes:
- Primarily Remote- Could potientally involve chart pick up if needed
- The more HEDIS experience, the better
- Strong experience with Excel
- Attention to Detail
- Flexibility
- Time management