MLTSS Quality Assurance Specialist

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Job Summary:

Job Profile Summary
This position is responsible for reviewing assessment and quality oversight activities for the MLTSS/DSNP Quality Assurance program. This position will be responsible for contributing to the efficient functioning of the MLTSS/DSNP Quality Assurance program by supporting the management staff with clinical interface in on-going monitoring assignments and ensuring care management compliance requirements are met. The case file audits conducted by this position include the review of care management operations compliance to contractual requirements relative to the State Medicaid Contract, CMS, NCQA, HEDIS and STARS. This position is also responsible for following up on corrective action plans based on audit data, and preparing periodic and year-end State and internal reportsResponsibilities:

• Responsible for conducting audits on member charts, including assessments (at least quarterly) for all areas of MLTSS/DSNP care management operations, which review daily business practice compliance to regulatory requirements relative to the State Medicaid Contract funded in part by the Centers for Medicare and Medicaid Services (CMS).
• Analyzes, prepares, documents and distributes audit reports/outcomes, including error trends, to the MLTSS/DSNP Department management for follow-up with care management staff; and conducts follow up reviews of corrective action.
• Comprehensively collaborates with the MLTSS/DSNP Department to review outcomes and then develop process improvement recommendations and changes as well as the need for and provision of continuous education/training opportunities.
• Presents MLTSS/DSNP Quarterly Audit and other Targeted Audit Reports and supporting findings during MLTSS/DSNP Subcommittee meetings of which the MLTSS Medical Director and other Directors are voting members.
• Organizes and prioritizes multiple projects within MLTSS/DSNP oversight activities, under the direction of the MLTSS/DSNP Manager, and communicates internally, with the MLTSS/DSNP Department and the Quality Management Department, as well as externally through attendance at State quality meetings, to recognize MLTSS program-wide improvement initiatives and participate in the implementation of strategies to improve the MLTSS/DSNP Program within HNJH.
• Conducts periodic targeted audits of various components of the MLTSS/DSNP program, against business process flows in order to evaluate compliance with MLTSS/DSNP standards.
• Responsible for collaborating with Analytic staff in the development of MLTSS/DSNP tool(s). These efforts include testing the audit tool, communicating feedback, and ensuring timelines are established and met.
• Develops/Assists with creating internal workflows to establish standardized guidelines for audits and other internal processes.

Disclaimer:
This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Education/Experience:

• High School Diploma/GED required
• Bachelor degree preferred or relevant experience in lieu of degree.
• Requires a minimum of 3 years experience in the health care delivery system/industry.
• Prefers three (3) years managed care experience in a customer-oriented capacity.
• Requires experience in chart reviews, indicators and databases.
• Working knowledge or regulatory agency standards and requirements desired.
• Requires quality initiative experience.

Additional licensing, certifications, registrations:

• Preferred Licensed Registered Nurse.

Knowledge:

• Required knowledge of medical terminology.
• Prefers knowledge of managed care principles.
• Requires knowledge of managed care health care delivery systems.
• Requires knowledge of performing chart audits or clinical chart audits.
• Requires compliance experience or long term care experience
• Prefer exposure to data compilation and presentation processes.
• Proficient knowledge of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Microsoft Outlook; client tracking and other electronic verification systems.
• Proficient knowledge of audit methodologies and procedures such as drawing random samples, creating graphs, and writing descriptive analyses to illustrate findings and make projections.
• Knowledge of the parame