Primary Accountability
Responsible for performing a wide range of duties to include, but not limited to, providing administrative support to the Clinical Systems Department. Will work primarily under the direction of the Managed Care Coordinator reviewing and auditing compliance related to managed care plans.
Description of Primary Duties & Responsibilities
1) Responsible for interpreting health plan HEDIS reports
a) Achieves positive impact on incentive monies earned for all health plans where opportunities exists
b) Maintains and generates quarterly HEDIS reports
c) Enters health plan members and data into Pay For Performance database with at least 95% accuracy rate
2) Notifies health plan member of needed service and schedules appointments :
a) Attempts to notify member will be achieved via: phone call, mail, email, and MyCare,
b) Prioritizes patient scheduling by according to due dates of needed services
c) Places health plan members on recall for coming due services
d) Executes all standing orders
3) Coordinates the various components of the annual HEDIS process working closely with the Managed Care Coordinator, Site QI Team and Health Plans.
a) Develops strategies and/or participates in HEDIS improvement initiatives
b) Assists the CSD with auditing and compliance of care services to include abnormal pap audit, PCMH population management, and other audits as required
c) Conducts medical record review/abstraction as necessary to support health plan and regulatory reporting
d) Coordinates on site medical record reviews/audits per health plan request
e) Is aware of various special health plan incentives and facilitates the completion of documentation to successfully obtain payment
4) Enters health plan members data into the Pay for Performance (PFP) database
a) Enters health plan members and data into the PFP database with an accuracy rate of at least 95%
b) Updates care guidelines within NextGen to assure accuracy of services due and completed
c) Completes documentation in the EHR that justifies completed or attempted outreach to health plan members
d) Keeps PFP database up to date to allow for accurate patient outreach
5) Assists the CSD with other activities as requested. This may include but is not limited to:
- Assisting in the completion of annual UDS audits
- Assisting in the management of PCMH status as requested
- Supports NextGen upgrades
- Other duties as needed
Description of Primary Attributes
General Development
1) Ability to work with a wide variety of people and develop professional working relationship with health plan staff
2) Ability to work well as part of a team and keep team members updated on current project development
3) Possess skills in motivation, self-direction and organization
4) Ability to adjust to changing circumstances, organize time efficiently and remain attentive to details
Professional and Technical Knowledge
1) Possesses some formal training, or equivalent experience in some of the aspects of the medical profession, typically acquired through a certificate or technical program lasting up to one year or through practical experience in a professional medical environment
2) Possesses an understanding of managed care plans, incentive programs and population management
3) Knowledge of medical office environment and clinical setting
4) Demonstrates the ability to analyze and interpret health plan reports
5) Knowledgeable in HEDIS services and relationship to quality patient care
Technical Skills
1) Proficient in Microsoft Office Suite
2) Ability to use clerical and numerical skills in preparing final drafts and documents from raw data
3) Ability to create letters, forms, documents, presentations
4) Ability to run reports, analyze and interpret data
5) Maintains working knowledge of EHR templates and workflow
Communication Skills
1) Possesses a professional level of written and verbal communication skills
2) Ability to communicate complex concept in a clear effective manner
3) Possesses excellent cross cultural communication skills and the ability to communicate to staff members at all levels
Physical Demands
Job duties are performed in the typical office environment of the organization, which requires ordinary ambulatory skills sufficient to visit other locations. The environmental factors and/or physical requirements of this position include the following:
1) Ability to stand, walk, stoop, kneel, crouch, frequently sit, and lift up to 25 lbs
2) Requires good hand-eye coordination, reach with arms & hands, and finger dexterity, including ability to grasp, and manipulate (using keyboard, office equipment)
3) Visual acuity to use keyboard, operate office equipment, and read printed material and regularly required to talk and hear
This job description in no way states or implies that these are the only duties to be performed by the employee(s) in this position. Employee(s) will be required to follow any other job-related instructions and to perform any other job-related duties requested by any person authorized to give instructions or assignments.
I have received and read a copy of my job description and fully understand the requirements.
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Signature Date
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Employee Name Printed
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