- R4429726
Department Name:
Quality
Work Shift:
Day
Job Category:
Risk, Quality and Safety
Estimated Pay Range:
$26.40 – $44.00 / hour, based on location, education, & experience.In accordance with State Pay Transparency Rules.
As a Health Plans Licensed Practical Nurse (LPN) Auditor, you will be an integral part of the Health Plan Quality Management Team. This role focuses on independent chart review, clinical assessment, and site visits.
Key Responsibilities:
- Independently review patient medical charts to assess compliance to AHCCCS and other regulatory rules.
- Make initial determinations based on clinical findings and documentation.
- Provide feedback and assistance to help the facilities reach compliance or maintain compliance.
Schedule: Monday–Friday, 8:00 a.m. – 5:00 p.m.
This is a hybrid position, and Arizona Residency is required. Some work can be done remotely with travel up to 50% of the time assigned facilities. Usually, 3 sites visit a week. With this hybrid/remote work, candidates must be self-motivated, possess moderate to strong tech skills and be able to meet daily and weekly productivity metrics.
Banner Plans & Networks (BPN) is an accountable care organization that joins Arizona’s largest health care provider, Banner Health, and an extensive network of primary care and specialty physicians to provide the most comprehensive healthcare solutions for Maricopa County and parts of Pinal County. Through BPN, known nationally as an innovative leader in new health care models, insurance plans and physicians are coming together to work collaboratively to keep members in optimal health, while reducing costs.
POSITION SUMMARY
This position coordinates and performs quality medical record reviews of the ambulatory medical record for PCP’s, OBGYN and High Volume Specialists (HVS). This position is also responsible for assisting the QM RN with the investigation and research of quality of care concerns that have been referred to the Quality Management Department for review and resolution. In addition, the position is also responsible for abstracting medical records, analyzing data and importing data to ensure that all contract requirements and UAHN/MHP initiatives are completed successfully and timely.
CORE FUNCTIONS
1. Assists in the development of clinical medical record audit tools and processes. Conducts data analysis using Microsoft Excel; Requests, compiles, sorts, prepares, reviews, validates, and analyzes data extracted from ManagedCare.com, TCS, medical records and survey tools using statistically reliable sampling methods.
2. Coordinates, retrieves, and performs medical record audits to determine provider compliance with established AHCCCS standards for documentation in conjunction with the re-credentialing process.
3. Monitors and tracks Corrective Active Plans (CAPs), in collaboration with the Manager, Supervisor or QM RN and communicates audit results to providers along with education about best practices and recommendations for improvement as outlined in established guidelines.
4. Provides written documentation and Corrective Action Plans as directed by the Credentials Committee to providers when necessary, and coordinates communication with the Credentialing Department.
5. Reports potential risk or compliance issues identified in the audit process to the Manager/Supervisor of QM. Assists in the development of QM policies and desktop procedures. Provides input and feedback on opportunities for improvement; Aggregates and analyzes medical record audit results on an annual basis for OFR required data. Participates in system-focused analyses in response to error identification.
6. Coordinates, collects data and prepares monthly provider profile data reports for the Credentialing Department. Coordinates, abstracts, and assists with the analysis of data from medical records in accordance with HEDIS specifications. Actively works with the HEDIS team to ensure understanding of performance measures, methodology and processes.
7. In collaboration with Director, Manager, Supervisor of Quality Management and Information Systems, creates datasets for review by the Quality and Medical Management Administration Staff and other department studies as assigned, including but not limited to setting up database and associated data entry programs, and retrieving data from the database for purposes of analysis or data review.
8. Supports the continuous improvement of the department, Medical Management, and UAHP through active participation in strategies to enhance organizational structure and processes. Responsible for working toward achieving full compliance in assigned areas for the annual AHCCCS operation review and complete all assigned work plan tasks.
9. This position works under supervision, prioritizing data from multiple sources to provide quality care and support. Incumbents work in a fast-paced, sometimes stressful environment with a strong focus on customer service. Interacts with staff at all levels throughout the organization.
MINIMUM QUALIFICATIONS
Current, unrestricted State of Arizona LPN license. Two years of experience, preferably in a family practice or pediatric medical office setting, with the ability to travel to all contracted sites, which may necessitate occasional overnight stays.
The ability to function both as a member of an interdisciplinary team as well as the ability to function independently. Excellent verbal and written communication skills and the ability to develop a strong rapport with providers and staff in a variety of clinical settings; Strong collaborative skills (ability to work with a team or individually). An aptitude for accuracy with attention to detail. Knowledge and understanding of HEDIS specifications; Strong leadership skills (can construct a vision, thinks creatively to solve issues and is goal oriented); the ability to maintain strict confidentiality along with good problem solving and investigative skills is required.
Ability to set appropriate priorities relative to work load in a fast paced environment; to implement standards and data sources, research tools, and other data collection instruments; to collect, analyze, describe, evaluate data, and write reports; to implement and track the effectiveness of process improvement; to recognize risk management concerns; and to review and extract significant data from medical records is required. Must be knowledgeable of the National Committee for Quality Assurance (NCQA), Health Plan Employer Data Information Set (HEDIS), Arizona Health Cost Containment System (AHCCCS) and Centers for Medicare and Medicaid Services (CMS) standards and reporting requirements.
PREFERRED QUALIFICATIONS
Additional related education and/or experience preferred.
EEO Statement:
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