Quality Practice Advisor
200 Center Point Circle Columbia, SC 29210
Job Title: RN / Quality Practice Advisor
Location: Columbia, SC USA 29210
Schedule: M-F 8: 00am - 5: 00pm
Pay: $32.00 - $35.00 hourly and weekly pay
Apply today with Ashley Kruger! 877-782-3334 or firstname.lastname@example.org
Establishes and fosters a healthy working relationship between large physician practices, IPA. Educates providers and supports provider practice sites in regards to the National Committee for Quality Assurance (NCQA) HEDIS measures. Provides education for HEDIS measures, appropriate medical record documentation and appropriate coding. Assists in resolving deficiencies impacting plan compliance to meet State and Federal standards for HEDIS. Acts as a resource for the market on HEDIS measures, appropriate medical record documentation and appropriate coding. Supports the development and implementation of quality improvement interventions and audits in relation to plan providers.
- Advises and educates large Provider practices and IPAs in appropriate HEDIS measures, medical record documentation guidelines and HEDIS ICD-9/10 CPT coding in accordance with NCQA requirements.
- Collects, summarizes and trends provider performance data to identify and strategize opportunities for provider improvement.
- Collaborates with Provider Relations to improve provider performance in areas of Quality, Risk Adjustment and Operations (claims and encounters).Delivers provider specific metrics and coach providers on gap closing opportunities.
- Identifies specific practice needs can provide support.
- Develops, enhances and maintains provider clinical relationship across product lines.
- Defines gaps in service relationship with providers and facilitate resolution.
- Leads and/or supports collaborative business partnerships, elicit client understanding and insight to advise and make recommendations.
- Partners with physicians/physician staff to find ways to explore new ways to encourage member clinical participation in wellness and education.
- Provides resources and educational opportunities to provider and staff.
- Captures concerns and issues in action plans as agreed upon by provider.
- Documents action plans and details of visits and outcomes and reports critical incidents and information regarding quality of care issues.
- Communicates with external data sources as needed to gather data necessary to measure identified outcomes.
- Provides communication such as newsletter articles, member education, outreach interventions and provider education.
- Supports quality improvement HEDIS and program studies as needed, requesting records from providers, maintaining databases, and researching to identify members' provider encounter history.
- Ensures that documentation produced and/or processed complies with state regulations and/or accrediting body requirements.
- Ensures assigned contract/regulatory report content is accurate and that submission adheres to deadline.
- Participates in and represents plan at community, health department, collaborative and other organizational meetings focusing on quality improvement, member education, and disparity programs, as assigned.
- Ensures accuracy in medical records for data collection, data entry and reporting. Enters documentation of findings in identified databases.
- A Bachelor' s Degree in Nursing
- State RN License
- 2+ years of experience in directly related HEDIS medical record review and/or Quality Improvement with experience in data and chart reviews to provide consultation and education to providers and provider staff Required
- 1+ year of experience in Managed Care experience Required
- Certified Coding Specialist (CCS)
- Demonstrated interpersonal/verbal communication skills
- experience with CPT and ICD-9
Keywords: Registered Nurse, RN, HEDIS, Milliman, InterQual, grievance, claims. management, audit, insurance, managed care, patient, patient healthcare, healthcare, dispute appeals, universal claims, complicated claims, outpatient, inpatient, telephonic utilization review, prior authorizations, case management, disease management, concurrent review, hospital, providers, member services, managed care, quality management, risk management, quality improvement, acute care, chronic care, critical care