PacificSource Health Plans

  • Clinical Quality Audit Coordinator

    Job Location US-OR-Bend
    Job ID
    2018-210
    Type
    Regular Full-Time
    Hiring Pay Range
    $68,000 - $74,000
    # of Openings
    1
    Status
    Exempt
  • Overview

    Position Overview: This position supports clinical performance improvement through medical record review and data validation audits aligned with Medicare, Medicaid and Commercial quality programs.  This position will develop and implement prospective and retrospective medical record review strategies to maximize CMS Star, NCQA HEDIS, and CCO QIM ratings.   This position will also be responsible for training temporary staff to complete annual projects within timelines.  

    Responsibilities

    Essential Responsibilities:

    1. Hire, train and coordinate temporary medical record review nurse team during annual submission timelines.
    2. Assist in the development and implementation of all aspects of audit projects within timelines.
    3. Ensures accuracy in medical records for data collection, data entry and reporting. Enters documentation of findings in identified databases.
    4. Performs medical record review and data validation audits according to State/Federal standards and NCQA HEDIS specifications. 
    5. Maintain audit accuracy standard of 98% or greater and meets minimum production standards. 
    6. Maintains working knowledge of HEDIS specifications and supplemental data sources.
    7. Assist in development of systems for collecting, maintaining, and utilizing data in collaboration with HEDIS Program Manager and Senior Software developer.
    8. Interfaces with a diverse range of clinical and administrative professionals, resolves complex issues, and performs data analytic and reporting activities.
    9. Collaborates with Quality, Risk Assessment, IT and Operations to develop and deploy aligned quality improvement programs to drive better provider satisfaction and quality outcomes.

    Supporting Responsibilities:

    1. Evaluate medical record review and data validation projects, initiatives and interventions to determine the effectiveness of activities and make recommendations to improve outcomes.
    2. Meet department and company performance and attendance expectations.
    3. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
    4. Perform other duties as assigned.

    Qualifications

    Work Experience: Acute care, primary care clinic or medical management experience preferred. Experience using or viewing electronic medical records. Experience performing chart audits. 

     

    Education, Certificates, Licenses: Valid Oregon nursing license or other clinical licensure required. 

     

    Knowledge: Valid Oregon nursing license or other clinical licensure required. 

     

    Competencies

    Our Values

    • Adaptability
    • Building Customer Loyalty
    • Building Strategic Work Relationships
    • Building Trust
    • Continuous Improvement
    • Contributing to Team Success
    • Planning and Organizing
    • Work Standards
    • We are committed to doing the right thing.
    • We are one team working toward a common goal.
    • We are each responsible for our customers’ experience.
    • We practice open communication at all levels of the company to foster individual, team and company growth.
    • We actively participate in efforts to improve our communities-internal and external.
    • We encourage creativity, innovation, continuous improvement, and the pursuit of excellence.

     

    Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.

     

    Physical Requirements: Ability to lift and carry and a laptop and case weighing approximately 15 lbs. Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions.  Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

     

    Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.

     

    PacificSource is an equal opportunity employer.  All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.

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