Position Purpose:

Employment Type:

Full time

Shift:

Day Shift

Description:

Conduct targeted reviews of medical documentation.

• Review medical records for patients identified by health plans, providers or HCPP as needed.
• Utilize provided guidelines to determine if criteria have been met relative to HEDIS, HCPP, MIPS, CMS Quality Reporting (formerly known as GPRO), PQRS and/or other quality of care standards as well as administrative or efficiency measures.
• Document in clinical reporting system and/or medical record any findings of medical record review as directed by Medical Director.
• Communicate findings with providers and other stakeholders.
• Assist in the education of providers and staff on the use of clinical reporting tools.
• Extract, query, send and/or present data quality reporting for stakeholders.
• Identify areas of improvement and plan corrective actions
• Investigate confidential patient health care data for purposes of determining patient qualification for placement of patients into appropriate care management programs or alerting Population Care Management RNs of health care needs and when appropriate generate necessary patient referrals/follow-up by outreach Fax/E-mail referrals.

Inform providers, provider staff and patients of potential needed appointments, procedures, or services. Assist with care coordination.

• Contact providers (phone, letter, fax, email) regarding patients who appear to have not met clinical quality, administrative or efficiency guidelines.
• Contact patients (phone, letter) regarding potentially unmet clinical care or administrative guidelines in a professional, accurate, efficient and courteous manner to obtain information and ensure good patient relations and a smooth care coordination process.
• Connect patients with providers for needed appointments.
• Work with health plan representatives to assist in updating, correcting and/or remediating quality or efficiency of care measure documentation as directed by management.
• Demonstrates the ability to effectively communicate with patients to facilitate and negotiate optimal care coordination and resolve patient inquiries with minimal supervision.
• Coordinate with Population Health Nurse actively working the case.

Health plan liaison for quality and administrative data; Utilize health plan data and portals

• Proficient in the access of various health plan applications for the purposes of viewing, modifying, editing, extracting and/or saving clinical and administrative data pursuant to departmental goals.
• Utilize HCPP, HCH, HCMG or other applications (EHR) to validate or compare health plan data.
• Update or modify health plan data pursuant to medical record review upon direction of management.
• Utilize knowledge of insurance and coding to ensure proper health plan reporting by providers.

Update, Support and verify accuracy of departmental data.

• Update internal data sources.
• Report to internal and external stakeholders changes in data.
• Data entry.

Provide departmental support

• Provide support to department as needed.

Demonstrate reliability in accepting and fulfilling various roles. Perform other job related duties within job scope as requested

• Self-motivated and able to work independently and manage multiple projects simultaneously with a high degree of logical judgment, analytical thinking, patience, attention to detail, and diplomacy
• Embraces continuous learning and regularly attends in-service programs and departmental meetings.
• Analyzes available patient information as necessary in Allscripts, Meditech, Care Evolution, and other available data systems.
• Demonstrates computer experience in data entry and Microsoft Office Products.
• Knowledge of internal and external resources/services which provide assistance to identified population.
• Demonstrates working knowledge of ICD-10 and CPT coding and medical terminology.
• Perform other job related duties as assigned.

Trinity Health's Commitment to Diversity and Inclusion

Trinity Health employs about 133,000 colleagues at dozens of hospitals and hundreds of health centers in 22 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Trinity Health's dedication to diversity includes a unified workforce (through training and education, recruitment, retention and development), commitment and accountability, communication, community partnerships, and supplier diversity.