Responsible for clinical file assessments for Care Management (inclusive of BH and UM). Identifies monthly insights for improvement and participates in Interrater Reliability meetings. Aids in efforts to continuously develop review tools to ensure validity of criteria, and appropriately captures evidence of expected clinical performance within contractual and Model of Care standards.
DEPARTMENT: Quality Improvement
REPORTS TO: Manager, Quality Improvement
- Conducts Care Management (UM, BH, CM) clinical file assessments by reviewing clinical documentation as assigned for Care Management for required clinical adherence.
- Participates in the development and ongoing review of clinical review tool to ensure that clinical elements accurately capture adherence with required performance standards.
- Reviews Care Management program descriptions, policies and procedures, step actions, and training materials as well as State Contracts when needed to evaluate alignment of review tool elements, departmental processes, staff training, and contractual/departmental standards.
- Utilizes clinical knowledge and experience to evaluate documentation of member health assessments, clinical needs and interventions in meeting compliance standards.
- Participates in meetings with Care Management and others to discuss review findings, areas of opportunity and recommendations for improvement.
- Appropriately escalates areas of concern identified during clinical file reviews.
- Participates as needed with preparation for State, CMS, and NCQA audits by collecting and /or reviewing clinical areas of relevance.
- Meets established productivity and IRR standards for file reviews.
- Follows departmental guidelines and processes.
- Other duties as assigned.
- Required a Bachelor's Degree in Nursing, Clinical Social Work/Counseling or Associate Degreed RN with 3 years of clinical experience
- Required 3 years of experience in a clinical environment (inpatient or outpatient)
- Required 1 year of experience in Managed Care (UM, BH, CM)
- Preferred familiarity with Medicare and Medicaid programs
Licenses and Certifications:
- Intermediate ability to effectively present information and respond to questions from peers and management
- Intermediate ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Intermediate demonstrated time management and priority setting skills
- Intermediate demonstrated written communication skills
- Intermediate demonstrated interpersonal/verbal communication skills
- Intermediate ability to create, review and interpret treatment plans
- Intermediate ability to read and interpret state and federal laws and regulations in relation to organization clinical documentation
- Intermediate ability to assess clinical documentation in relation to audit standards and make recommendations for improvement based on findings
- Advanced ability to work as part of a team
A license in one of the following is required:
- Required Licensed Registered Nurse (RN)
- Required Licensed Clinical Social Worker (LCSW)
- Required Licensed Mental Health Counselor (LMHC)
- Required Licensed Marital and Family Therapist (LMFT)
- Preferred Certified Case Manager (CCM)
- Required intermediate Microsoft Excel
- Required intermediate Microsoft Outlook
- Required intermediate Microsoft Word
- Preferred intermediate Healthcare Management Systems (Generic)