Quality Educator
MMM Holdings
San Juan, PR, US
hace 1 día

Job Description

BUSINESS UNIT : Castellana Physician Services

POSITION : Quality Educator

POSITION DESCRIPTION

This position is responsible to serve as primary liaison between Castellana, Physician, IPA Medical Directors & MSO Medical Directors and their offices staff for the purposes of providing service, education, and issues resolution for performance improvement initiatives, and projects that impact the overall plan rating.

Establishes strategies based in Member Experience Measures.

ESSENTIAL DUTIES AND RESPONSIBILITIES

It is required that each Quality Educator reviews, learns and applies technical knowledge about Five Stars methodology including, but not limited to : HEDIS measures, pharmacological treatment measures, evaluation periods, population identification for measures, CMS Technical notes and any other applicable regulation that impacts the rating.

Tasks include activities under the following key areas of the Five Stars Operations :

Quality Educator : Duties & Responsibilities

1.Supports identification of targets for interventions; providers need based on QIMS

2.Established strategies, initiatives and educational plans based on Non-Compliance measures to improve quality metrics, to guarantee a raw quality rating of 4.

75 or more; including assigned PCPs

3.Generate, analyze and distribute all the related PCPs reports; including but not limited to : TSRs, Dashboards, QIMS, among others

4.Weekly calls to the offices in the region assigned to the PCP with the greatest opportunity in quality measures.

5.Responsible to bring viable solutions to any issues received.

a.Channels specific data validation requests

1.Diagnosis issues identification

2.Exclusions

3.Eligibility discrepancies

4.Delay in medical claims processes

5.Others

b.Channel and investigate specific Stars reports discrepancy issues with including interactions with :

1.Five Star Operation

2.IPA Network Management

4.Coding

5.Claims Medical Process

6.Visit PCP to carry out Quality, HEDIS and Billing evaluations, following established policies and procedures in offices by Region and Sub Ipas

7.Identifies provider with educational needs based on the medical record review in order to guide them about the opportunities identified.

8.Providers Level Interventions Support : PCP Work Plan File, YTD documentation, including but not limited to meetings summary, support documents, assistance and agenda, among others

a.Generate associated QIMS Reports

  • Analyze results and identify improvement opportunities
  • Channel and investigate specific stars reports discrepancy issues including interactions with other departments
  • Development and monitoring of strategic stars objectives
  • 9.Identifies and Discuss the findings identified after reviewing the medical records with the provider and or administrator, as appropriate.

    10. Coordinate multidisciplinary clinic that support quality measure

    11. Develop and monitoring formal work plan to strategic stars objectives by Region and PCP

    a.In offers alternatives and tools to the provider on how to document, validate and coding in the medical record, in order to cover the identified needs.

    12. Develops and monitoring corrective action plans for the provider that does not meet the established quality metrics standards and discusses deficiencies in medical practice with the regional Medical Director.

    13. Meeting with the PCP, Office Staff and Medical billing company to evaluate areas of opportunity in the office

    14. Quality Workshop for Castellana PCPs and medical Office Staff

    15. Training, Education and on the street mentoring (Interdepartmental targeted training sessions

    16. Active participation in the PPE, Area and Share Saving Meetings. Provide follow-up until resolution to all assigned duties as part of the process

    17. Leadership role in implementing Ideas and guiding staff member toward accomplishment of designated tasks and assurance or quality and performance improvement

    18. Foster Interpersonal relationships, showing empath and understanding towards staff, protecting individual self-esteem.

    Understand own impact on others; interact effectively with peers, subordinates and supervisors.

    19. Coordinates the provision of health education and preventive health in PCP office if necessary or requested for PCP.

    20. Collaborate in the publication of the quarterly newsletter (Castellana News)

    21. Participates in the evaluation of departmental processes and presents recommendations

    22. Attend al required workouts

    23. Make presentations at provider group meetings or other forums, as requested

    EDUCATION AND EXPERIENCE

    Bachelor’s degree in health or business-related field or comparable experience. Minimum three years’ experience in a healthcare environment.

    Prefer someone with health plan, medical billing and coding or customer service experience. Evidence of good communication, interpersonal and problem solving skills.

    GENERAL ABILITIES AND KNOWLEDGE

  • Knowledge on HEDIS measures, Stars Methodology, Coding, Provider Compensation Model, Claims Billing Cycles, and CMS regulation.
  • Knowledge of internal applications such as Innovamd, Medhok, Clinical Dashboard, among others
  • Computer literate, preferably in the following applications : Word, Excel, Power Point and Outlook.
  • Ability to respond to a high volume of work and always maintain a polite and professional manner.
  • Able to function with frequent interruptions.
  • Ability to prioritize workloads for maximum efficiency.
  • Customer Service Skills : practicing, valuing and supporting service to both internal and external customers
  • Time Management Skills : establishing priorities and accomplishing tasks in a timely manner
  • Teamwork : ability to work in a team environment to create solutions to problems
  • Fully Bilingual (English and Spanish)
  • GENERAL SKILLS

  • Have strong interpersonal skills.
  • Excellent verbal and written communication skills.
  • Typing Skills
  • Multiple Task : Ability to write and maintain in the call focuses at the same time
  • LANGUAGE SKILLS

    Ability to read and comprehend simple instructions, short correspondence, and memos. Ability to write simple correspondence.

    Ability to effectively present information in one-on-one and small group situations to customers.

    MATHEMATICAL SKILLS

    Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume.

    Ability to apply concepts of basic algebra and geometry. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

    REASONING ABILITY

    Define problems, collect data, establish facts, and draw valid conclusions. Interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.

    INTERPERSONAL RELATIONS

    Internal Contacts

  • Staff employees
  • Management at all levels of the organization
  • MSO and Plan employees
  • External Contacts

  • External Providers
  • External Clients
  • Vendors
  • Government and Federal Agencies as necessary
  • Position requires sitting and standing associated with a normal call center environment. Regularly talks and hears. This position requires that weight be lifted, or force be exerted up to 30 pounds.

    ENVIRONMENTAL AND WORKING CONDITIONS

    Normal busy office environment (examples : business office with computers and printers, light traffic). The noise is typically moderate.

    Travel around different locations required. General exposure to weather conditions while traveling. Valid driver’s license required.

    A flexible schedule which could involve evening, holiday and weekend work.

    This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve.

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