Clinical Performance Improvement Coordinator
Less than 5 years experience • Business Services
Organize and coordinate activities to ensure full compliance with all regulatory and licensing agencies (e.g., CMS, MDCH, and NCQA) and employer groups relative to medical management activities, including accreditation site surveys and regulatory reviews. Coordinate, facilitate, assess and evaluate improvement initiatives utilizing process improvement methodology.
- Provide support in developing and maintaining NCQA accreditation and compliance with regulatory standards. In doing so, coordinates preparation for NCQA and other state, federal and employer group regulatory processes. Responsibility includes summarizing and analyzing accreditation standards and reports, preparation of reports/presentations for BCN committees and leadership and assisting in evaluating strategic initiatives in relationship to new and existing standards.
- Provide support in developing and administration of delegation oversight agreements for new and existing BCN delegates. Perform file review and audits of delegated entities to identify compliance and non-compliance and develop recommendations for corrective actions.
- Perform retrospective review to validate clinical criteria and medical necessity requirements, reduce practice pattern variation, identify best practice providers, and monitor billing and reimbursement practices. Prepare quality reports through data collection, data input and report development. Perform quality audits for all Care Management professional team members including nurses and physicians. Provide objective assessment of documentation requirements through ongoing case review. Audit results are compiled, team members are coached based on the audit results, and results are presented to the team leaders. Areas for improvement may be identified which may include training or reinforcement of previously trained materials. Conduct physician advisor quality audits. Compile results and share with the Associate Medical Director. Act as liaison and provide support for the care management leadership team. Assist in development and implementation of policy and procedure, and development of programs. Act as intermediary between internal functional areas and with other departments in relation to care management initiatives. Develops quality improvement activities to prevent occurrence of adverse outcomes, including consistent benefit administration (i.e. timeliness of decision, appeal turnaround, etc.).
- Serve as customer communication lead for care management. Responsible for the coordination of the care management portion of the Provider Manual and provider newsletter through interface with the corporate provider communication team. Responsible for coordination of care management’s portion of the member newsletter, and external communication tools such as the member handbook and website.
- Responsible for activities related to the Clinical Quality Committee and Care Management Advisory Council. Assists in development of agenda, completes quality review of materials, and participates in committee meetings. Acts as a liaison within the care management department to coordinate agenda topics, and obtain necessary reports and materials from various function areas and departments company-wide.
- Conduct quality improvement studies for Care Management to assist in identification of quality variances, including over and under utilization. Investigate and analyze quality related issues/incidents reported by internal team members, members or providers, which may result in less than optimal quality of care for BCN members, adverse exposure or potential legal risk for the corporation. Assist in crisis management of unusual consequences which result from member, employer group or provider dissatisfaction. Acts as a liaison to Quality Management, Provider Services, Customer Services, Corporate Communications, senior leadership and legal counsel.
- Coordinate written responses to RFI’s. Measure Care Management’s compliance with customer expectation. Develop and implement corrective action plan to meet or exceed customer expectations. Provide recommendations based on analysis.
- Responsible for oversight of HEDIS initiatives assigned to care management. Provides oversight of process to improve HEDIS rates related to above. Responsible for the monitoring and oversight of member satisfaction for the department. Acts as department liaison related to the company’s CAHPS workgroup.
- Promote and engage in positive and constructive daily team work, participate in after hours call schedule and perform other duties as needed. Work with an inter-disciplinary team including members of Quality Management, Provider Services and Customer Services improve quality-related issues.
- Other duties as assigned.
- Registered nurse with unrestricted, current Michigan license required.
- Bachelor's degree in nursing, allied health, risk management or other health care related field preferred.
- CPHQ certification preferred
- Risk management certification preferred.
- Four (4) years of acute patient care with broad clinical background required.
- Three (3) years quality management/ performance improvement experience with at least one (1) yearaudit/reporting experiencepreferred. Will also consider utilization management, discharge planning or case management experience in place of up to two years of quality management/assurance experience.
- Experience in a managed care environment preferred.
- Managed care philosophy, policies, and procedures.
- Clinical criteria/guidelines for appropriateness, setting/level of care, and concurrent patient management.
- Medical management processes across the continuum of care.
- Knowledge of outcomes management
- Knowledge of quality reporting components.
- Ability to identify, assess and resolve highly complex problems relating to the delivery of medical services to members.
- Knowledge of CQI quality management principles and program.
- Standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing.
- Knowledge of accreditation process, such as National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Commission (URAC),
- Knowledge of regulatory processes, such as, Centers for Medicare and Medicaid Services (CMS) and Michigan Department of Community Health (MDCH)
- Current medical practices using alternative care settings and levels of service-home care, skilled nursing facilities, subacute, hospice and home infusion.
- Case management and disease state management processes preferred.
- Knowledge of BCN reimbursement policies preferred,
- Knowledge of project management principles preferred.
- Local/national community resources preferred.
- Medical terminology and ICD-9 and CPT coding.
- BCN HMO and BCBSM POS benefits and program requirements as relates to medical management preferred.
- State and federal HMO regulations preferred.
- Excellent written and verbal communication
- Excellent documentation
- Excellent customer service
- Excellent statistical, analytical, problem-solving and decision making
- Strong organizational, planning and implementation
- Well developed time management and prioritization
- Good negotiating skills
- Good interpersonal/team relations
- PC literate
- Ability to work well with minimal supervision