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Clinical Quality Management Analyst

Company: Allegheny Health Network
Location: Harrisburg
Posted on: May 3, 2021

Job Description:

Company : Highmark Inc Job Description : JOB SUMMARYThis job works with appropriate departments in the areas of compliance, process improvement, medical record review and coding, and member and provider satisfaction for all product lines. Recommends and implements process improvements related to the potential of quality medical care and service to members and to improve documentation of these services for appropriate ICD 10-CM coding. Serves as a resource and educator regarding provider and office staff medical record documentation, federal and state standards including CMS and NCQA standards and continuous quality improvement principles. Perform special studies per audits, conducting office site visits and medical records reviews, ensuring improvement in performance for various initiatives in a timely manner. May coordinate credentialing, re-credentialing, member complaint investigations, Medical Director site visit requests, facility site visit requests, activities to include other reviews, audits, accreditation activities as requested on behalf of the organization. ESSENTIAL RESPONSIBILITIES Develop and manage process improvement initiatives from the Organization for member and providers to include detailed data analysis, process analysis, report generation, medical record documentation, and HCC Coding. Conduct, collect and analyze information and data from office site and/or medical record reviews to continually improve the care, services, proper documentation and coding for members, to properly assign ICD10-CM codes to chronic conditions, and coordination with the revenue programs, credentialing and quality improvement programs to improve STARS, value based care and achieve and maintain accreditation. Monitor changes, corrections and clarifications in applicable regulatory/accrediting body requirements and make adjustments to the compliance plan and to follow CMS Coding Guidelines. Conduct retrospective, concurrent, and prospective, semi-annual and annual audits, identify gaps and communicate results. Conduct continuing education to providers on STARS, HEDIS, and HCC Coding. Conduct re-audits as needed Other duties as assigned or requested. EDUCATIONRequired Current state RN or LPN license or Bachelor's degree in a Healthcare-related field Substitutions 6 years of progressive medical coding experience Preferred None EXPERIENCERequired 3-5 years of relevant, progressive experience in the area of specialization Preferred None LICENSES OR CERTIFICATIONSRequired CPC, CRC, RHIA, or CCS Certification Preferred None SKILLS An understanding of Total Quality Management (TQM) concepts, techniques, process and outcome measurements ( 1-2 years) An understanding of statistics is also preferred in order to analyze various reports and validate study methodologies (1-2 years) Excellent verbal communication skills and professional manner, excellent written communication skills and a familiarity with a variety of writing styles. Must be able to communicate with medical administrators, including Medical Directors and Physician Advisors related to problem identification, action plan implementation, ongoing monitoring and problem resolution. (1-2 years) Demonstrated computer literacy and knowledge of information systems and comparative data bases. Working knowledge of Microsoft Office software (Word, Excel, Access, PowerPoint, etc.) (1-3 years) Well-developed, analytical and problem solving skills with the ability to understand and interpret clinical data Prior project management experience preferred (1-3 years) Language (Other than English): NoneTravel Requirement: 0% - 25%PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONSPosition Type Office-basedTeaches / trains others regularly OccasionallyTravel regularly from the office to various work sites or from site-to-site RarelyWorks primarily out-of-the office selling products/services (sales employees) NeverPhysical work site required YesLifting: up to 10 pounds ConstantlyLifting: 10 to 25 pounds OccasionallyLifting: 25 to 50 pounds NeverDisclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. Referral Level Payout 2Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. EEO is The Law Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.orgCalifornia Consumer Privacy Act Employees, Contractors, and Applicants NoticeBENEFITSTotal Rewards Program In addition to competitive pay rates and flexible career growth, we show our employee appreciation through a comprehensive Total Rewards package, including: Medical and prescription drug, dental and vision coverages for your and your eligible dependents Health Saving and Flexible Spending Accounts Life, AD and disability insurance Employer-sponsored 401(k) plan Paid time off, including paid holidays Tuition reimbursement Volunteer opportunities Voluntary benefits Employee discounts Wellness Resources and Programs Employees have access to the following wellness programs and resources: Work-life resources, such as employee assistance programs and financial counseling services 24/7 telephone access to health and wellness coaching to achieve personal goals Onsite pharmacy services at major campuses Fitness center access for all employees inclusive of showers, lockers, and group exercise classes at major Highmark campuses, Allegheny General Hospital & West Penn Hospital Access to chronic condition management programs when enrolled in the employer-sponsored medical plan 100% coverage for preventive exams, including flu shots Incentive program that rewards employees Secure bicycle parking at major campuses Healthy food options at onsite cafeterias Employee networks to gather in the name of health Onsite seated massage and stress management classes including yoga, mindfulness and meditation LIVING IN PITTSBURGHPittsburgh, PA is home to Highmark Health's corporate headquarters, as well as the headquarters of many of our businesses and a majority of our career opportunities. When you live and work in Pittsburgh, you'll experience a wide variety of lifestyle advantages. Take a look around and you'll quickly see why Pittsburgh is one of America's most liveable, most affordable, safest and happiest cities. Learn more about this exciting and inviting location:ABOUT PITTSBURGH VIBRANT PITTSBURGHLocationFacilityCareer Path

Keywords: Allegheny Health Network, Harrisburg , Clinical Quality Management Analyst, Other , Harrisburg, Pennsylvania

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