Coordinate and ensure that all communication is maximized effectively related to key processes and coordination between the practice, health plan, and any disease management vendor(s) associated with the Pay for Quality Program.
- Participate and coordinate in all medical record audits and assist with communication between the practice staff and physicians.
- Facilitate resolution of any discrepancies found during an audit between the medical record findings and disease management program placement.
- Implement and maintain process for ongoing patient chronic disease identification. Communicate to the Health Plan clinical information for review and disease management placement.
- Maintain process to gather information within the medical record and identify missing standards of care for an office visit/point of care event.
- Document P4Q measure compliance within the CCHS provided web based applications LUMERIS validate claims, lab, and pharmacy data as well as face to face encounters for each member.
- Maintain an accuracy level of 95% on QA audits to be conducted a minimum of two times per year.
- Ensure any pertinent point of care information is communicated appropriately. After an office visit, send clinical information to the Health Plan and/or vendor for member communication / calls.
- Maintain and update treatment alerts and flow sheets for the member within the medical record (paper or EMR) Utilize the CHS provided web based application (LUMERIS) to set ticklers and follow up for member appointments.
- Notify the enrollment and/or customer service department via the CHS provided web based application (LUMERIS) of any changes or anomalies in member record information.
- Develop and maintain process that encourages all CHS members to receive a minimum of one PCP visit per year.
- Coordinate with the practice lead physician to create and implement standing orders.
- Identify and implement process to identify members that are in need of preventive screening tests and issue correspondence to prompt members to receive test.
- Provide feedback to practice physicians regarding process improvement and opportunities for improvement.
- Identify and communicate social services needs with the Health Plan for action.
- Participate and assist with HEDIS medical record audit data collection process as instructed by the Health Plan.
- Maintain current list of CHS members to identify new patients and incorporate into existing P4Q activities.
- Collaborate with local Practice Coordinators regarding process improvement, communication efforts, barriers/challenges, and understanding of overall program processes.
- Participate in all operational meetings/calls as identified between the practice physicians and the Health Plan.
- Communicate with the Health Plan appropriately and provide positive and constructive feedback on an ongoing basis.
- Collaborate internally with physicians and staff to properly code disease categories.
- Assist the Health Plan with data collection efforts related to proper coding, documentation, and data collection.
- Utilize the Health Plan data to identify members applicable to the coding process.
- Assist within the practice to reinforce training conducted by the Health Plan regarding the coding process and data collection efforts.
Job Related Skills:
- Communicates information accurately and timely to internal and external staff. Written and oral communication is accurate and timely and at the appropriate level.
- Ability to articulate information to personnel at all levels of understanding.
- Ability to handle multiple tasks, set priorities, and develops action items.
- Detail oriented.
- Works independently, receiving a minimum of detailed supervision and guidance.
- Word, Excel and Access experience preferred.
Licensed Practical Nurse (LPN)
Unrestricted licensure in the applicable state
1. Creates and manages all CHS medical records and flow and alert within the CHS provided web based application (LUMERIS) for all members
MOE: All medical records contain a flow and alert sheet produced by the application.
2. Submits all alert forms and/or communicate appropriate information regarding point of care (POC) encounter to the Health Plan and/or vendor.
MOE: Health Plan and/or vendor receive alert/treatment forms after POC.
3. Maintains process for ongoing identification of P4Q disease specific members and communicates appropriate clinical information for disease management program placement.
MOE: Health Plan received communication regarding new members or existing members with newly identified disease process with appropriate clinical information. Estimated communication based on volume of new membership and disease processes identified during an audit.
4. Actively and productively participates in all market level Practice Coordinator and Health Plan conference calls.
MOE: Participates in weekly call with minimal absences.
5. Maintains detailed understanding of all P4Q measures to ensure proper documentation within the medical record and communication with physicians when standards are not met.
MOE: Participates and verbalizes understanding during the baseline and subsequent audits appropriate level of understanding and provides evidence of communication with physicians as identified. Participate during coordination calls or during the audit process.
6. Conducts medical record audit as identified by the Health Plan. Maintains and updates the member clinical data in the CHS provided web based application (LUMERIS) on a daily basis. Validates the claim lab and pharmacy data in the application that corresponds to the clinical data in the medical record
MOE: Effectively manages audit process to collect clinical measures / indicators and complete data entry in a database for reporting. QA score of no less than 95% must be maintained