Job Summary Reports to Team Lead, Clinical Quality and Record Review. Works independently and with other departments and/or vendors to ensure clinical potential quality issues are tracked, investigated and resolved in accordance with TRICARE and Plan requirements. Primarily responsible for conducting post-service in-depth clinical reviews (all care settings) in accordance with accepted standards of care. The overall goal is to improve clinical service delivery. Responsibilities Clinical Review Utilizes clinical expertise to conduct clinical case retrospective reviews to determine deviation from standard of care or gaps in care and presence of mandatory data elements. Document progress of investigation and findings in internal databases and/or Excel spreadsheets. Conduct clinical literature reviews and summarize findings. Contact providers/facilities, as applicable, to obtain information and/or medical records needed to conduct a comprehensive clinical review of cases and final determinations. Conduct chart reviews and audits both electronic and at medical facilities and providers’ offices. Abstract data relevant to review target. Write succinct and targeted investigative summaries. Write quality review determination letters. Develop and manage collaborative relationships with internal/external stakeholders and vendor staff. Maintain confidentiality of all medical records, correspondence and related documents. Effectively meets strict deadlines. Aware of the potential for fraud and waste and how to report suspected fraudulent activity. Data Analysis and Reporting Participate in collection and analysis of data for clinical CDRL reports (i.e., monthly quality issue report, AHRQ PSI report, annual clinical quality management program report). Participate in collection, analysis and presentation of data for Peer Review, Credentials Review and Quality Committees. Evaluate data for trends. Continuous Quality Improvement Participate in continuous quality improvement activities/root cause analysis to resolve identified quality issues and ensure forward movement in beneficiary service delivery. Cross-train and perform other duties as assigned or required within the Quality Department. Attends meetings to achieve departmental/organizational goals and objectives. Experience 1-3 years of healthcare quality management experience. 1-3 years of clinical nursing experience. Quality assurance/improvement experience in a managed health plan, integrated health care system, or health care accreditation or regulatory agency. Skills/Competencies Ability to read, abstract and analyze medical records as well as other clinical data. Analytical mindset with excellent organizational and problem-solving skills. Ability to work both independently and as a team member. Strong project management skills. Intermediate statistical analysis expertise including interpretation of data. Communications: Effective verbal and written communication skills. Able to work collaboratively with different teams and different team members. Ability to work both independently and as a team member. Manages assigned caseload in accordance with established performance metrics. Excellent customer service skills. Understanding of medical terminology, anatomy, physiology and concepts of disease and health. Fundamental knowledge of ICD-10, CPT and HCPCS coding. Understanding of Medicare, Medicaid and/or TRICARE. Proficient in Microsoft Office, including but not limited to Excel, Outlook, PowerPoint and Word. Experience in Access and Visio a plus. Ability and inclination to adopt technology to maximize efficiency. Decision making: Identification of clinical quality issues as evidenced by deviation from accepted standard of practice or gap in care. Ability to recommend corrective actions and/or sanctions. Education/Certifications/License Current and unrestricted state RN or LPN/LVN license required (CT, NJ, NY, PA) BA, BS, or BSN preferred
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