Job Code/Title: A4001 / Quality Improvement Specialist Population Health
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This position will facilitate and help to coordinate the implementation of Population Health Care Management Quality Programs within the Health System. They will work within the Department of Population Health and assist in the development of programs for patients enrolled in value based care agreements and other patient cohorts. This individual will also collaborate across various clinical and non-clinical departments to educate on, assist with implementation of and compliance to, various Population Health Care Management and Federal Quality initiatives. A person in this role must have the ability to listen and effectively communicate with staff members, clinicians, business stakeholders and non-clinical departments in order to be successful in their role. They must apply critical thinking and judgement when designing, developing and implementing assigned projects and programs to meet the goals of targeted patient groups and program stakeholders.
The following statements are intended to describe, in broad terms, the general functions and responsibility levels characteristic of positions assigned to this classification. They should not be viewed as an exhaustive list of the specific duties and prerequisites applicable to individual positions that have been so classified.
Under the direct supervision of the Director of Population Health Care Management (PHC), this person will coordinate and implementation of Population Health Care Management Quality Programs within the Health System. Works collaboratively with providers, clinic management, data analytics, and the IT department to educate, provide support and track compliance with Population Health Care Management and Federal Quality initiatives. Reviews clinical documentation to ensure appropriate content.
Duties and Responsibilities
- Develops and conducts Population Health Care Management training for clinical staff, providers, and other stakeholders within the Health System.
- Identifies improvement opportunities for PHCM initiatives based on data analysis and needs assessment.
- Works with clinic management and providers to operationalize improvements.
- Assists with the development and operationalization of clinical care pathways and programs to benefit patients.
- Incorporates up-to-date knowledge of HEDIS, STARS, Federal Quality measures and best practices into care management programs.
- Reviews clinical documentation to ensure that it supports appropriate diagnosis codes and meets requirements for clinical indicators; including validation of ICD code submissions for accuracy and compliance with Risk Adjustment documentation standards.
- Works with payor, providers, and coding teams to ensure HCC clinical documentation requirements and quality performance targets are met annually.
- Analyzes coding quality review outcomes and develops formal written performance reports on a quarterly basis, with target of 95% accuracy.
- Navigates the electronic health records, auditing tools, and other relevant software applications to review, analyze and report on pertinent data.
- Develops and delivers professional presentations.
- Assists in the development of policy and procedures when appropriate.
- Performs administrative and procedural tasks using critical decision-making skills.
- Performs miscellaneous job-related duties as assigned.
Knowledge, Skills and Abilities
- Knowledge of process improvement practices.
- Exercises independent judgment to manage and impart confidential information.
- Ability to communicate effectively, both orally and in writing, with all levels of the organization.
- Proficient in the use of computers, word processing, data entry, and database management.
- Familiarity with risk adjustment and auditing.
- Knowledge of CMS regulations and thorough understanding of potential areas of risk for fraud and abuse in regards to coding and documentation.
Minimum Job Requirements
Bachelor’s Degree in a health-related field with at least 3 years of ambulatory care experience, preferably in a large healthcare system. Verification of education and licensure (if applicable) will be required if selected for hire.
Conditions of Employment
- Must be employment eligible as verified by the U.S. Dept. of Health and Human Services Office of Inspector General (OIG) and the Government Services Administration (GSA).
- Must pass a pre-employment criminal background check.
- Fingerprinting, and subsequent clearance, is required.
- Must provide proof of varicella & MMR immunity or obtain vaccinations within 90 days of employment.
- Must obtain annual influenza vaccination.
- If this position is assigned to a clinical area, successful candidate will be required to complete a pre-placement medical evaluation/health screen. Required N-95 mask fitting, testing, vaccinations to include annual TST, Tdap, and Hepatitis B will be determined based on location and nature of position.
Working Conditions and Physical Effort
- Work is normally performed in a typical interior/office work environment.
- No or very limited exposure to physical risk.
- Work involves sitting most of the time, but may involve walking or standing for brief periods of time.Walking and standing are required only occasionally and all other sedentary criteria are met.
- Sedentary Work: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.
- No or very limited physical effort required.