Reports To: VP, Quality Improvement
Position Location: Tampa, FL
Job Level: Exempt
- 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.