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Senior Clinical Quality Reviewer (LPN, RN, LMSW)

Job Ref: 91919
Location: Downtown NYC

In Person: 1-2 days per week
Salary Range: $103,000.00 – $113,000.00

About Client

Cure Staffing, Inc, DBA Cure the Executive Edge has partnered up with one of NYC’s most prevalent and prestigious insurance providers. Our client provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, and network including primary care providers, specialists and participating clinics. Over the last three decades, our client has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life and we are excited to help them accomplish this goal. We are seeking qualified, appropriately skilled professionals who can provide reliable and professional support. All candidates must have education, experience, licenses, and certifications that are applicable and appropriate to the level of this position.

Position Overview

The primary function of the Senior Clinical Quality Reviewer is to assess and audit medical charts for compliance with a focus on HEDIS, QARR, Medicare Advantage Star measures, CRG and quality improvement activities. This position will assist in the development and participate in the implementation of initiatives across a broad array of clinical measures and health improvement activities. Quality audit findings from this position will contribute to the support and training of physicians on proper coding and medical record documentation practices to support improvement in quality metrics. As a result, this role will be required to conduct regular internal provider audits and then document, summarize, and report findings. Additionally, participation in the annual HEDIS and QARR hybrid medical record review project will be required. This role may also participate in member outreach and education as needed to ensure members receive appropriate services. In addition, this position will provide support and training to physicians on proper coding and medical record documentation practices to support improvement in quality metrics.

The position will be designated as telecommuting and will require conducting field work including in-person provider meetings, on-site chart review or collection, and/or coming to the main office, as needed.

Job Description

  • Maintain expert knowledge of medical record review and EMR systems.
  • Maintain up-to-date knowledge of HEDIS, QARR and Star specifications and function as a subject expert on all HEDIS/QARR measures.
  • Distribute requests for records and schedules appointments with provider offices to ensure timely completion of duties to meet internal and regulatory standards and requirements.
  • Perform clinical audits via EMR, in-house paper medical records, on-site provider visits to measure compliance with preventive health guidelines and to measure effectiveness of quality improvement initiatives.
  • Identify, track and report variation from standards of care by audit of core operations, patient care processes and medical record documentation.  Designs interventions to drive improvement and minimize variation from standards of care.
  • Data enter accurate and timely clinical quality findings in the appropriate system(s) in accordance with established documentation standards for the organization to ensure integrity of member services provided over the continuum of care and over time.
  • Will implement quality improvement activities as directed by Quality Management programming needs
  • Support interdepartmental and internal teams focused on process improvement projects and outcomes.
  • Complete on-site provider visits and/or meetings monthly to conduct education sessions regarding appropriate coding practices and medical record documentation practices.
  • Responsible for auditing provider site for coding practices and medical record documentation and identify areas for improvement.
  • Independently monitor provider specific HEDIS report cards identify areas of concern and recommend improvement plans with minimal oversight.
  • Share CRG Non-user and Chronic Fall Out rates, member lists and diagnosis categories. Engage providers to implement activities to improve risk scores for Chronic Fall Out members and decrease of non-users.
  • Monitor provider/facility progress on monthly basis; prepare and distribute monthly member gap in care reports and partner with community provider/staff to coordinate closure of gaps in care through.
  • Initiate strategic plan to motivate providers and office staff to meet measure goals. 90% of the priority measures assigned to work on for designated site/facility should reach or exceed benchmark goals as set forth by QARR percentile/Star rating via chart review and/or member outreach throughout the year.
  • Facilitate retrieval of medical record documentation and work with provider group(s) and in-field navigators to retrieve electronic and paper records that supports HEDIS/QARR.
  • Records findings of patient encounters to include patient identifiers, relevant information, and results in database.
  • Participate in the annual HEDIS and QARR hybrid medical record review project:
    • Independently work with provider offices to retrieve and review charts in support of HEDIS & QARR annual data collection. Assist staff with provider offices they are unable to retrieve and review records.
    • Ability to train and lead temporary staff in the review of medical records (electronic and paper-based)
    • Ability to train temporary staff on EMRs and databases used during the MMR project.
    • Supervision of temporary staff during the MRR project
    • Serve as a final reviewer of HEDIS and QARR records.
    • Maintain a 95% accuracy rate during the MRR project.
  • Other duties as assigned by Senior Manager of Quality Management Operations or Vice President of Quality Management

Minimum Qualifications

  • Bachelor’s Degree required; and
  • 5-7 years of experience with medical record review/audit working on HEDIS/QARR in a health plan setting; or
  • An equivalent combination of training, educational background and experience in related fields and educational disciplines.
  • Prior experience in Quality Improvement in a health care and/or Managed Care setting strongly preferred.
  • Knowledge of HEDIS and NYS QARR specifications required.
  • Knowledge of ICD-10 and CPT codes required.
  • Intermediate knowledge of Microsoft Office applications including Word, Excel, PowerPoint, Access, and Visio.
  • Experience with relationship management.
  • Ability to travel within the service area.
  • Active NYS clinical license required

Professional Competencies

  • Ability to proficiently read and interpret medical records.
  • Ability to measure compliance and identify deficiencies in chart documentation against standards.
  • Ability to work in a team setting and independently prioritize projects and assignments.
  • Integrity and Trust
  • Customer Focus
  • Functional/Technical skills
  • Written/Oral Communication
  • Bilingual a plus
  • Ability to work in a team setting.
  • Ability to provide oversight and training to clinical and clerical resources.
  • Must know how to use Microsoft Office applications including Word, Excel, and PowerPoint and Outlook.
  • Ability to form effective working relationships with a wide range of individuals.

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