Responsible for non-clinical (CMC, PSO, UM, DME) file audits. 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: Health Services
REPORTS TO: Sr. Director, Field Health Services
- Conducts nonclinical (CMC, PSO, UM, DME) file assessments by reviewing non-clinical documentation as assigned for required adherence.
- Participates in the development and ongoing review of non-clinical review tool to ensure that non-clinical elements accurately capture adherence with required performance standards.
- Reviews non-clinical 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 knowledge and experience to evaluate non-clinical team documentation
- Participates in meetings with coordination teams and others to discuss review findings, areas of opportunity and recommendations for improvement.
- Appropriately escalates areas of concern identified during non-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.
- Assist with special projects and other duties as assigned.
- Required a High School diploma or GED
- Preferred a Bachelor's Degree in a related field
- Required 3 years of experience in a managed care setting, medical office or facility setting with demonstration of medical administration duties.
- Preferred familiarity with Medicare and Medicaid programs
- 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 interpersonal/verbal communication skills
- Intermediate demonstrated written communication skills
- Intermediate ability to work as part of a team
- Intermediate ability to read and interpret state and federal laws and regulations in relation to organization clinical documentation
- Intermediate ability to assess documentation in relation to audit standards and make recommendations for improvement based on findings
- Required intermediate Microsoft Outlook
- Required intermediate Microsoft Word
- Required intermediate Microsoft Excel
- Preferred intermediate Microsoft PowerPoint
- Preferred intermediate Healthcare Management Systems (Generic)