Senior Clinical Quality Management Analyst

Company :

Highmark Inc.

Job Description : 

JOB SUMMARY

This job works with appropriate departments in the areas of compliance, process improvement, medical record review and coding, and member and provider satisfaction for all product lines.  Recommends and implements process improvements related to the potential of quality medical care and service to members and to improve documentation of these services for appropriate ICD 10-CM coding.  Serves as a resource and educator regarding provider and office staff medical record documentation, federal and state standards including CMS and NCQA standards and continuous quality improvement principles.  Perform special studies per audits, conducting office site visits and medical records reviews, ensuring improvement in performance for various initiatives in a timely manner.  May coordinate credentialing, re-credentialing, member complaint investigations, Medical Director site visit requests, facility site visit requests, activities to include other reviews, audits, accreditation activities as requested on behalf of the organization. 

ESSENTIAL RESPONSIBILITIES

• Develop and manage process improvement initiatives from the Organization for member and providers to include detailed data analysis, process analysis, report generation, medical record documentation, and HCC Coding.
• Conduct, collect and analyze information and data from office site and/or medical record reviews to continually improve the care, services, proper documentation and coding for members, to properly assign ICD10-CM codes to chronic conditions, and coordination with the revenue programs, credentialing and quality improvement programs to improve STARS, value-based care and achieve and maintain accreditation.
• Monitor changes, corrections and clarifications in applicable regulatory/accrediting body requirements and make adjustments to the compliance plan to follow CMS Coding Guidelines.
• Conduct retrospective, concurrent, and prospective, semi-annual, and annual audits, identify gaps and communicate results. Conduct continuing education to providers on STARS, HEDIS, and HCC Coding. Conduct re-audits as needed.
• Other duties as assigned or requested.

EDUCATION

Required

• RN non-state specific license or LPN license or Bachelor's Degree in a Healthcare-related field

Substitutions

• 6 years of combined experience with RN/LPN, Risk Adjustment HCC Coding, medical coding/billing, HEDIS, and/or health related field in lieu of bachelor's degree

Preferred

• None

EXPERIENCE

Required

• 5 years of combined experience with RN/LPN, Risk Adjustment HCC Coding, medical coding/billing, HEDIS, and/or health-related field

Preferred

• 1 year of project management experience

LICENSES AND CERTIFICATIONS

Required

• RN or LPN or
• CPC, CRC, RHIA, RHIT, or CCS Certification

Preferred

• None

SKILLS

• An understanding of Total Quality Management (TQM) concepts, techniques, process and outcome measurements
• An understanding of statistics is also preferred in order to analyze various reports and validate study methodologies
• Excellent verbal communication skills and professional manner, excellent written communication skills and a familiarity with a variety of writing styles. Must be able to communicate with medical administrators, including Medical Directors and Physician Advisors related to problem identification, action plan implementation, ongoing monitoring, and problem resolution.
• Demonstrated computer literacy and knowledge of information systems and comparative data bases. Working knowledge of Microsoft Office software (Word, Excel, Access, PowerPoint, etc.)
• Well-developed, analytical and problem-solving skills with the ability to understand and interpret clinical data

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally