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Clinical Quality CoordinatorJob ID 6215426 Date posted 11/08/2017
The EA Clinical Quality Coordinator is responsible for managingthe auditing and appeals functions for the Erickson Advantage plan related toUnited Health Care/Centers for Medicare/Medicaid requirements. She/ he interfaces with the EricksonAdvantage leadership team and members of the health plan team across all communitiesto obtain required data and documentation required for the auditprocesses. The EA Clinical QualityCoordinator manages the auditing and preparation for the clinical businessmonitoring and other Special Needs Plan requirements. The incumbent participates in the health planquality management functions supporting the data analytics, QCI processimprovement plans and reports.
- Manages the monitoring, auditing and reportingrequirements related to monthly, quarterly and annual regulatory and compliancerequirements. (30%)
- Manages Special Needs Plan regulatoryrequirements related to health risk assessments, model of care training, andnurse monitoring requirements etc.
- Manages monthly and quarterly organizationaldetermination reporting requirements.
- Supports the Director of Quality and CareManagement for the Annual Audit for delegated functions of health plan.
- Conduct the member and staff satisfactionsurveys yearly.
- Project coordinates the 5 Stars Program deliverablesand HRA process (30%)
- Responsible for managing the HRA process for allhealth plan member groups for achieving the Medicare 5 Star ratings. Responsible for tracking progress of keydeliverables for all components of the HRA outreach process and coordinatingefforts with field based staff to achieve HRA resident confidentiality andabides by resident rights and responsibilities.
- Responsible for the management of the 5 Starprogram quality and customer service measures initiatives relative tocoordination, tracking and follow-up for achieving the 5 Star status. Assistswith preparation for field chart reviews as related to Five Star measures andDelegation audit.
- Manages the appeal process related to timelinessand documentation requirements per regulatory and health planrequirements. Some rotating weekendcoverage required for responding to appeals request. (15%)
- Participates in quality managementactivities. Assists with quality audits,preparing documentation, reports, obtaining data, and supporting onsite auditinitiatives. (25%)
- Knowledge of medical terminology for reviewingclinical documentation and health care quality measures (e.g. HEDIS and Fivestars measures).
- Knowledge of health care and insuranceindustries and health care delivery systems
- Computer skills in Excel, WORD, Outlook and abilityto use a variety of software applications to maintain records, analyzealternatives, evaluate trends, and to assist in problem-solving and decision-makingresponsibilities.
- Honed interpersonal skills to interface withphysicians, members of the healthcare team, residents and family members.
- Analytical skills to evaluate problems and recommendalternative solutions.
- Ability to work in a dynamic, team-orientedenvironment.
Associates Degree in a related field required. In lieu ofdegree, a minimum five years of experience in health care quality measures,medical chart review, clinical quality auditing, working as an MDS coordinator,or in a clinical setting is required. Computer skills related to database managementand use of electronic medical record systems preferred.