Quality Outreach Unit Representative II - JHP

Job Details

Job Description

Primary Responsibilities:

• Perform investigations of potential quality of care concerns referred to the QM Department from multiple internal resources and external sources such as but not limited to: UM, Care Management, Complaints and Grievances and Provider Tip Line.
• Perform quality of care reviews on cases identified as Preventable Serious Adverse Events, based on the CMS / DPW Bulletin.
• Procure medical records as indicated based on case review.
• Perform clinical reviews on medical records to verify QOC issues, PSAEs, or payment retractions.
• Work collaboratively with Claims and Operations and Medical Management to ensure the PSAE review process is seamless and meets with regulatory requirements.
• Perform medical record reviews and use clinical judgement to determine if issues are identified.
• Create summaries of medical record reviews and collaborate with Medical Director when indicated. Presents and participates in all applicable cases approved by Senior Medical Director to Credentialing Committee for peer review.
• Prepare identified cases for internal physician peer reviews and presents cases at credentialing meeting.
• Prepare cases for external peer review as needed.
• Maintain timeliness in all case reviews and investigations.
• Identify opportunities to work with providers to ensure a quality-of-care partnership and act as a liaison for quality and patient safety for par facilities and par providers.
• Utilize the Healthcare Management integrated software system to build and track cases referred for quality of care, member complaints and PSAE's.
• Participate in annual required training and competency testing for inters rater reliability.
• Participate in evaluation process with QM Management Team to identify recommendations for process improvement.
• Contribute to the development and enhancement of documentation, tracking tools and process flows for quality monitoring and audit activities as assigned by the Management Team.
• Participate in practitioner medical record review process for HEDIS when indicated, PA Performance Monitoring and other regulatory or QM related activities. Participate in work groups as assigned.
• Attends inter-departmental meetings alongside QM manager and Director; updates processes and/or workflow activities to departments such as Utilization Management and Complaints and Grievances, and Credentialing Committee.
• Other duties as assigned.

Education:

• Graduate of accredited school of nursing, RN
• 2 years of experience in quality management monitoring activities and/or credentialing/ recredentialing reviews, development, implementation, and evaluation of quality management activities in acute and/or ambulatory health care settings.
• Managed care experience preferred. Knowledge of medical coding preferred.

Skills/Abilities:

• Excellent verbal and written communication skills.
• Ability to present and discuss clinical quality of care issues with QM Manager and Medical Director.
• Strong analytical and problem-solving skills.
• Strong organizational skills and ability to manage multiple priorities.
• Knowledge of NCQA standards preferred.
• Ability to function independently with minimal supervision.
• Basic understanding of QM principles.
• Basic computer skills in Outlook, MS Word, Excel and Access preferred.

Work Shift

Worker Sub Type

Primary Location Address

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.

Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.