POSITION PURPOSE: Provides ongoing VBS/HEDIS medical record collection and abstraction; and supports the abstraction of medical records related to VBS/HEDIS compliance initiatives. Provides accurate assessment of provider performance against VBS/HEDIS standards and procedures. Adheres to strict HIPAA confidentiality requirements for protected health information. Administrative oversight for all VBS and care management staff. Certify compliance with all ACOs and MSOs requirements and ensure all metrics are met.

Assist the Director of Population Health in implementation of all aspects of the Care Management Program, including the identification of opportunities to improve patient care. Will be responsible for the planning, direction, and coordination of care management operations, including quality, customer service, financial performance, and regulatory compliance. Provide oversight to departmental staff.

POSITION REQUIREMENTS / QUALIFICATIONS:

Education/Experience: Graduate from an accredited College or University with a bachelor’s degree in business administration, social services, or health-related field. A minimum of 2+ years of experience in clinical care management activities.

Licensure / Certification: Maintain current CPR certification from the American Heart Association. Coding certification desired.

Skills / Ability: Medical and Managed Care Terminology, Keyboard, Knowledge of Medicare, Medicaid, and Managed Care coverage benefits/limitations, NCQA VBS/HEDIS requirements. Knowledge of ICD10 and CPT Coding. Basic computer knowledge is preferred.

POSITION RESPONSIBLITIES (THIS IS AN EXEMPT POSITION):

 Performing accurate & comprehensive reviews of medical records for VBS/HEDIS measures.

 Auditing high volumes of medical records to ensure correct and appropriate code assignment.

 Ability to multitask and troubleshoot problems independently.

 Ensuring accurate data entry for claim submission.

 Oversee daily operations, manage Population Health staff and administrative components associated with this department

 Develop and oversee budget for the VBS department

 Develop, implement, and manage performance improvement of Medicare VBS/HEDIS program while identifying and articulating results, barriers, and opportunities

 Drive strategic direction and development of program while reviewing and communicating results of program and projects to leadership

 Identifies reporting needs and requirements to monitor VBS/HEDIS project performance and participates in the design and creation of these reports

 Develops program success measures and documentation to track and regularly report program status using a standard documentation tool

 Ensures awareness of and adherence to NCQA standards and industry trends, communicates changes to internal partners and establishes if updates are needed to VBS/HEDIS documents/processes used for training or medical record retrieval

 Medical record review, data abstraction, and quality experience.

 Schedule appointments with health care provider including appointments to PCP for their health risk assessments, preventative visits, and chronic care management.

 Participate in Performance Improvement Activities.

 Participate in appropriate continuing education in service training.

 Maintain current licensure and/or certificates.

 Ability to read and interpret medical documents.

 Ability to prioritize, multi-task, and achieve goals on time; work independently and to motivate others.

 Strong data entry skills; capable of using a computer efficiently and effectively.

 Able to navigate and master practice management and EHR software programs.

 Treat clients, team members and the public with courtesy, respect and present a positive public image.

 High production environment and candidates must adhere to measured productivity requirements.

 Research medical history to determine the most appropriate and source of necessary documentation.

 Based on a strong knowledge of HEDIS criteria identify the medical information that supports the specific HEDIS measure.

 Responsible for obtaining, organizing, and securing a large volume of medical records within a limited timeframe.

 Adhere to department Policies and Procedures in performing duties and assignments.

 Demonstrates the ability to work with a diverse population.

 Ability to post appropriate CPT Category II Performance Measure codes after chart review and audit.

 Reports to work on time and ready to work with minimal absenteeism.

 Adheres to Confidentiality Policies and Procedures / HIPAA Regulations.

 Well organized with the ability to maintain attention to detail.

 Ability to work independently and as a team member.

 Coordinates activities and daily workloads to Population Health staff.

 Supervises daily activities and daily workloads of department with day-to-day monitoring and prioritizing of workflows and activities.

 Ensure hospital discharge are addressed appropriately.

 Assists in posting Category II Performance measures to appropriate insurance plans.

 Publish reports on all HEDIS Gaps and daily productivity.

 Daily communication with Managed Care Organizations regarding Hospital Admissions/discharges and Compliance.

 Performs QA audits to efficiently reduce number of charts retrieved from providers.

 Attends scheduled in-services and trainings.

 Follow-up and track missed appointments.

 Track coordination of referrals for outcome results.

 Coordinates home visits if warranted for non-compliant patients.

 Assist families to access the health care system and assign to a medical home.

 Performs other duties as assigned.